All citations for Lutheran Convalescent Home

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Lutheran Convalescent Home

Last standard health inspection on record

November 7, 2024

Showing 1 to 21 of 21 citations

  1. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of September 13, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2019).

  2. No harm, with potential for more than minimal harm

    Ensure medication error rates are not 5 percent or greater.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0759, Pharmacy Service Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  3. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  4. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  5. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  6. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  7. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  8. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  9. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  10. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  11. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  12. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  13. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  14. No harm, with potential for more than minimal harm

    Install an approved automatic sprinkler system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of September 13, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2019).

  15. No harm, with potential for more than minimal harm

    Meet requirements for the use of electrical equipment.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0919, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 13, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2019).

  16. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 13, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 25, 2019).

  17. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  18. No harm, with potential for more than minimal harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of November 7, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2024).

  19. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  20. No harm, with potential for more than minimal harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  21. No harm, with potential for more than minimal harm

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0625, Resident Rights Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.