Lutheran Sunset Home
LUTHERAN SUNSET HOME in GRAFTON, ND — inspection on February 26, 2026.
Found 7 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 facility policy titled Resident Rights occurred on 02/26/26.
This policy, dated 11/17/16, stated, . 1.
Resident rights.
The resident has the right to a dignified existence . -Review of Resident #2's medical record occurred on all days of survey.
The care plan stated, .Total dependence with toileting hygiene, product change and clothing adjustment .
Observation on 02/24/26 at 8:52 a.m. and 9:28 a.m. showed Resident #2's room door ajar and the resident lying in bed uncovered with pants pulled down under the buttocks and the brief exposed. -Review of Resident #8's medical record occurred on all days of survey.
The care plan stated, Problem: Generalized pruritis [itchy skin] . sits with no clothes on in .room . fabric causes . itch. doesn't like . door to . room closed tight so a curtain was placed in . room to provide privacy when . in . room naked.
Observations of Resident #8 on 02/26/26 at 8:26 a.m. and at 10:25 a.m. showed Resident #8 asleep in a recliner, naked from the waist down, and the door to the room open.
Staff failed to use the privacy curtain which left the resident exposed to visitors, staff, and other residents.
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
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
Review of the facility policy, Personal Fans, occurred on 02/26/26.
This policy, dated February 2025, stated, .
Personal fans must be cleaned and disinfected on a routine basis .
Cleaning of personal fans shall be done no less than monthly by environmental services staff.
Observations on February 23-24, 2026, showed the following: -Resident #10's room: Dust/debris on a small oscillating fan.
The resident stated, The rooms get cleaned every week; however, the fans don't get cleaned often. -Resident #13's room: Dust/debris on a small oscillating fan.
The resident stated staff clean fans when they have time.
During an interview on 02/25/26 at 8:15 a.m., an environmental staff member (#6) stated staff should clean personal fans monthly. -Observation of Resident #42's room on 02/23/26 at 1:54 p.m. identified an area approximately 5-inch by 3-inch in size missing paint. -Observation of Resident #47's room on 02/23/26 at 2:03 p.m. identified missing paint and sharp/rough pieces of wood on the cabinet under the sink, and walls missing paint. -Observation of Resident #82's bathroom on 02/23/26 at 2:07 p.m. showed moisture damage to the wall and warped molding.
During an interview on the afternoon of 2/26/26, an environmental staff member (#6) confirmed Resident #42, #47, and #82's rooms needed repair.
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
stated, .
Dietary aide reported to writer that this resident [Resident #40] had struck another resident
noise out by the nurse station and it bothers him in his room.
Writer told resident that it is never okay
never gets in trouble for making noise.-Review of Resident #2's medical record occurred on all days of survey and identified diagnoses of Alzheimer's Disease, dementia with psychotic disturbance, hallucinations, and anxiety. A quarterly MDS, dated [DATE], identified severely impaired cognition. A progress note, dated 08/24/25 at 7:11 p.m., stated, .
Dietary aide reported that this resident [Resident #2] had been struck on the cheek by another resident [Resident #40] when he was going to the dining room.
She stated that the male resident stopped and said something to this resident and when she made a noise, he had struck her, hard, on the cheek.
Writer assessed resident and found no injury present.
Writer asked resident if she was okay and she said yes but she doesn't think he likes her very much.
During an interview on 02/25/25 at 2:55 p.m., an administrative staff member (#11) confirmed the facility investigated incidents that occurred on 08/24/25 and 08/30/25.
The facility failed to protect Resident #2 from physical abuse and Resident #37 from sexual abuse.
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
authorities.
record review, review of facility policy, and staff interview, the facility failed to report potential abuse
resident-to-resident altercations.
Failure to report potential abuse to the State Survey Agency (SSA) placed Resident #2 and all other residents at risk for possible abuse and/or physical injury.Findings include:
Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 02/25/26.
This policy, dated 02/13/24, stated, .
Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents [sic] that cause the allegation do not involve abuse and do not result in serious bodily injury to the .
State Survey Agency .
Report the results of all investigation to the .
State Survey Agency, within 5 working days of the incident .-Review of Resident #2's medical record occurred on all days of survey and identified diagnoses of Alzheimer's Disease, dementia with psychotic disturbance, hallucinations, and anxiety. A quarterly MDS, dated [DATE], identified severely impaired cognition. A progress note, dated 08/24/25 at 7:11 p.m., stated, .
Dietary aide reported that this resident [Resident #2] had been struck on the cheek by another resident [Resident #40] when he was going to the dining room.
She stated that the male resident stopped and said something to this resident and when she made a noise, he had struck her, hard, on the cheek.
Writer assessed resident and found no injury present.
Writer asked resident if she was okay and she said yes but she doesn't think he likes her very much.-Review of Resident #40's medical record occurred on all days of survey and identified diagnoses of psychosis, delusions, intermittent explosive disorder, traumatic brain injury, and mild intellectual disabilities. A quarterly MDS, dated [DATE], identified moderately impaired cognition.
The care plan stated, . He is not orientated to time and has difficulty with recall. 'explodes' . if there is a lot of noise. He has hit other residents in the fact [sic] and pushed them with his 4WW [wheeled walker].
When it gets too loud outside his room, he may start yelling to 'Shut up!' .
During an interview on 02/25/25 at 2:55 p.m., an administrative staff member (#11) confirmed the facility failed to report the above incident to the SSA.
See F-F600
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
Observation showed a mechanical dish-washing machine, which is used three times a day for washing dishware and utensils.
The dietary staff member identified the dishwasher uses heat to sanitize the dishware and utensils.
When asked to see the temperature log of wash and rinse temperatures, an unidentified staff member on the unit stated they do not check the temperature gauges on the dish machine and they have never kept a log.
The surveyor placed an irreversible temperature measuring device in the dish machine and the dietary staff member (#4) started the dish machine.
The temperature of the wash cycle and the rinse cycle did not reach the minimum temperatures per policy.
The dietary staff member started the dishwasher for a second cycle and the wash gauge reached 155 degrees F, the rinse temperature reached 195 degrees, and the irreversible temperature measuring device reached 165 F.
The dietary staff member (#4) confirmed staff should monitor the dish machine to ensure the proper temperature is reached to wash and sanitize the dishware and utensils.
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
During an interview on 02/26/26 at 10:03 a.m., a facility staff member (#2) confirmed the medical record for Resident #85 lacked the hospice election form.
355084 02/26/2026
Lutheran Sunset Home 333 Eastern Ave Grafton, ND 58237
Review of Resident Council Meeting minutes occurred on 02/25/26.
The meeting minutes, dated 10/17/25, identified two residents had concerns regarding nebulizer tubing left lying on the floor. -Observations on 02/23/26 at 2:07 p.m. and 3:25 p.m., on 02/24/26 at 8:37 a.m., and on 02/26/26 at 12:56 p.m. showed a nebulizer mask and tubing on the floor next to Resident's #82's recliner.
During an interview on 02/26/26 at 12:56 p.m., Resident #82 stated the nebulizer machine, mask, and tubing are always on the floor.