Faith Lutheran Home
FAITH LUTHERAN HOME in WOLF POINT, MT — inspection on March 13, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Quality Assurance and Performance Improvement Committee Minutes, dated 12/23/24 and 1/22/25, showed no documentation the committee continued to meet monthly in February 2025.
Review of the facility's plan of correction, dated 1/6/25, showed:
.
Audits will be presented to QAPI team monthly, for discussion of results and issues to maintain compliance.
After 3 months, QAPI committee/IDT will determine the need for ongoing and frequency of the audit to ensure substantial compliance . [sic]
Interviews identified an administrator was not employed as of late December 2024.
Due to this, the QAPI committee did not include the necessary staff, as required by the Centers for Medicare and Medicaid, to participate in the QAPI meetings.
Review of the Appendix PP, State Operations Manual, for
F-F585 - The management and oversight of the grievance process
F-F600 - Abuse, Neglect, and Misappropriation
5609 - Abuse Reporting
During this call, both staff stated they did not wish to work that many hours above their already full-time employment.
275073
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 275073 B.
Wing 03/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201
F-F835 - Administration
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
275073
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 275073 B.
Wing 03/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201
F-F837 for the facility failing to employ a licensed Nursing Home Administrator.
275073
F-F849 - Hospice Abuse Reporting/Handling potential for actual harm
F-F868, shows the facility must have the following positions participate in the QAPI Committee:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.
Refer to