All citations for St Luke Lutheran Community-Portage Lakes

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 St Luke Lutheran Community-Portage Lakes

Last standard health inspection on record

November 27, 2024

Showing 1 to 20 of 20 citations

  1. 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.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Establish an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0001, Emergency Preparedness Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Use approved construction type or materials.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0161, Construction Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

  5. 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 August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

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

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Ensure proper usage of power strips and extension cords.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Provide properly protected cooking facilities.

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

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

    Health citation F-0561, Resident Rights Deficiencies. Inspection of August 5, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 30, 2024).

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

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

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

    Health citation F-0604, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Provide safe and appropriate respiratory care for a resident when needed.

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

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of October 25, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 16, 2023).

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

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of August 1, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 16, 2019).

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.