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 26 to 50 of 55 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 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

    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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

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

    Meet other general requirements that are deficient.

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

    Fire safety citation K-0500, Services Deficiencies. Inspection of November 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 10, 2025).

  8. 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).

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

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

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

    Fire safety citation K-0211, Egress Deficiencies. Inspection of June 27, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 13, 2022).

  10. 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 June 27, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 13, 2022).

  11. 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 June 27, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 13, 2022).

  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

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of January 29, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 3, 2025).

  15. 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 January 29, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 3, 2025).

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

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of January 29, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 3, 2025).

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

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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

    Health citation F-0582, Resident Rights Deficiencies. Inspection of November 27, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 10, 2025).

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

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of November 27, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 10, 2025).

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

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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

    Health citation F-0800, Nutrition and Dietary Deficiencies. Inspection of November 27, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 10, 2025).

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

    Respond appropriately to all alleged violations.

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

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 30, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (October 25, 2024).

  21. 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 September 30, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (October 25, 2024).

  22. 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).

  23. 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).

  24. 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).

  25. 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).

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.