Napoleon, OH

Lutheran Home

2-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1036 South Perry Street, Napoleon, OH

(419) 592-1688

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1998-10-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

68%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,035

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.26

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.88

Baseline 18.65% · Performance 20.56% · Measure score 1.88 · Achievement 1.88 · Improvement 0

Healthcare-associated infections

3.36

Baseline 5.66% · Performance 6.83% · Measure score 3.36 · Achievement 3.36 · Improvement 0

Total nurse turnover

Baseline 73.33% · Performance 90.00% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.06

Baseline 3.03 hours · Performance 3.67 hours · Measure score 2.06 · Achievement 2.06 · Improvement 1.81

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.47%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 12.82% · Lower 95% interval 7.88%
Discharge to community	55.26%	50.57% 4.7 pts better	No Different than the National Rate · Eligible stays 54 · Observed rate 53.7% · Lower 95% interval 43.45%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	94.74%	95.27% 0.5 pts worse	Numerator 36 · Denominator 38
Falls with major injury	2.63%	0.77% 1.9 pts worse	Numerator 1 · Denominator 38
Discharge self-care score	52%	53.69% 1.7 pts worse	Numerator 13 · Denominator 25
Discharge mobility score	44%	50.94% 6.9 pts worse	Numerator 11 · Denominator 25
Pressure ulcers or injuries, new or worsened	7.89%	2.29% 5.6 pts worse	Numerator 3 · Denominator 38 · Adjusted rate 7.18%
Healthcare-associated infections requiring hospitalization	6.83%	7.12% 0.3 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.86%
Staff COVID-19 vaccination coverage	1.89%	8.2% 6.3 pts worse	Numerator 1 · Denominator 53
Staff flu vaccination coverage	2.04%	42% 40 pts worse	Numerator 2 · Denominator 98
Discharge function score	40%	56.45% 16.5 pts worse	Numerator 10 · Denominator 25
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.8 0.5 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.3	1.8 1.5 pts worse	1.8 1.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.5 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.8%	92.4% 0.4 pts better	93.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 92.1% · Q3 91.2% · Q4 96.3% · 4Q avg 92.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.5%	94.5% 2 pts worse	95.5% 3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of long-stay residents experiencing one or more falls with major injury	5.1%	3.3% 1.8 pts worse	3.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.3% · Q3 5.9% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	26.1% 26.1 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	8.8%	6.2% 2.6 pts worse	5.4% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 13.3% · Q3 3.7% · 4Q avg 8.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	32.7%	25.4% 7.3 pts worse	19.6% 13.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 35.5% · Q3 29.6% · 4Q avg 32.7%
Percentage of long-stay residents who received an antipsychotic medication	5.3%	11.5% 6.2 pts better	16.7% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.1% · Q3 4.2% · 4Q avg 5.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.7%	7.7% 3 pts better	16.3% 11.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.9%	6.2% 2.3 pts better	14.9% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.9% · Q3 0.0% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.5% 0.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	37.0%	21.7% 15.3 pts worse	19.8% 17.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 30.8% · Q3 55.6% · Q4 32.1% · 4Q avg 37.0%
Percentage of long-stay residents with pressure ulcers	0.7%	3.7% 3 pts better	5.1% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.1%	78.1% 16 pts better	81.7% 12.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 91.3% · 4Q avg 94.1%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.2%	75.6% 0.6 pts better	79.7% 3.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-05 · Fire 2024-09-05

7 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2022-06-30 · Fire 2022-06-30

13 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-07-25 · Fire 2019-07-25

21 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

7 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-30

F · Potential for more than minimal harm 2024-09-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-30

F · Potential for more than minimal harm 2024-09-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-09-30

E · Potential for more than minimal harm 2024-09-05

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-09-30

F · Potential for more than minimal harm 2022-06-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-08-01

F · Potential for more than minimal harm 2022-06-30

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-08-01

E · Potential for more than minimal harm 2022-06-30

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-08-01

F · Potential for more than minimal harm 2019-07-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-09-13

F · Potential for more than minimal harm 2019-07-25

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2019-09-13

E · Potential for more than minimal harm 2019-07-25

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2019-09-13

E · Potential for more than minimal harm 2019-07-25

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2019-09-13

E · Potential for more than minimal harm 2019-07-25

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2019-09-13

E · Potential for more than minimal harm 2019-07-25

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2019-09-13

E · Potential for more than minimal harm 2019-07-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-09-13

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-09-05

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-09-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-09-05

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-09-05

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-09-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-09-05

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2024-09-30

C · Minimal harm 2024-09-05

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-04-22

F580 · Resident Rights Deficiencies

Health

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

Corrected 2024-05-08

D · Potential for more than minimal harm 2023-12-18

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-12

D · Potential for more than minimal harm 2023-12-18

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-01-12

D · Potential for more than minimal harm 2023-12-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-12

F · Potential for more than minimal harm 2022-06-30

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2022-08-01

D · Potential for more than minimal harm 2022-06-30

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-08-01

C · Minimal harm 2022-06-30

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2022-08-01

B · Minimal harm 2022-06-30

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2022-08-01

F · Potential for more than minimal harm 2019-07-25

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2019-09-13

F · Potential for more than minimal harm 2019-07-25