Cycle 1
Health 2024-11-21 · Fire 2024-11-21
15 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Arlington Hts, IL
Lutheran Home For The Aged
4-star overall rating with 2-star inspections with $164,159 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
800 West Oakton Street, Arlington Hts, IL
(847) 253-3710
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
354
Certified beds
Average residents
226
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
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
1.11
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,970
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.80% · Performance 23.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.42
Baseline 4.58% · Performance 6.51% · Measure score 4.42 · Achievement 4.42 · Improvement 0
Total nurse turnover
6.91
Baseline 62.65% · Performance 35.45% · Measure score 6.91 · Achievement 6.91 · Improvement 6.70
Adjusted total nurse staffing
3.85
Baseline 3.91 hours · Performance 4.17 hours · Measure score 3.85 · Achievement 3.85 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 1975 · Observed rate 9.82% · Lower 95% interval 9.97% |
| Discharge to community | 64.36% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 1933 · Observed rate 63.06% · Lower 95% interval 62.35% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.76% |
95.27%
2.5 pts better
|
Numerator 960 · Denominator 982 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 9 · Denominator 982 |
| Discharge self-care score | 67.51% |
53.69%
13.8 pts better
|
Numerator 532 · Denominator 788 |
| Discharge mobility score | 52.41% |
50.94%
1.5 pts better
|
Numerator 413 · Denominator 788 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 18 · Denominator 982 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 1012 · Observed rate 5.24% · Lower 95% interval 4.87% |
| Staff COVID-19 vaccination coverage | 21.14% |
8.2%
12.9 pts better
|
Numerator 89 · Denominator 421 |
| Staff flu vaccination coverage | 73.06% |
42%
31.1 pts better
|
Numerator 320 · Denominator 438 |
| Discharge function score | 67.89% |
56.45%
11.4 pts better
|
Numerator 535 · Denominator 788 |
| Transfer of health information to provider | 30.06% |
95.95%
65.9 pts worse
|
Numerator 199 · Denominator 662 |
| Transfer of health information to patient | 95.6% |
96.28%
0.7 pts worse
|
Numerator 174 · Denominator 182 |
| Resident COVID-19 vaccinations up to date | 5.54% |
25.2%
19.7 pts worse
|
Numerator 27 · Denominator 487 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.3
1.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
89.6%
2 pts better
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 93.2% · Q3 88.8% · Q4 91.1% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.1% |
91.6%
1.5 pts worse
|
95.5%
5.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.4% · Q3 3.3% · Q4 1.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
50.3%
49.4 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.7% · Q4 1.4% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
6.5%
1.2 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.7% · Q3 8.1% · Q4 4.7% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
18.5%
3.9 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 12.5% · Q3 16.5% · Q4 17.2% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
22.8%
4.7 pts better
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.4% · Q3 18.8% · Q4 14.5% · 4Q avg 18.1% · 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 | 10.2% |
17.2%
7 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.6% · Q3 8.2% · Q4 6.5% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
15.0%
9.1 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.3% · Q3 4.2% · Q4 2.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 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 | 0.2% |
1.7%
1.5 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
21.3%
2.1 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 22.6% · Q3 18.2% · Q4 22.0% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.2%
0.5 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.3% · Q3 6.8% · Q4 4.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
68.8%
2.8 pts better
|
81.7%
10.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.5% · Q2 69.7% · Q3 70.9% · Q4 75.0% · 4Q avg 71.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
14.0%
6.4 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.6% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.2% · Q2 0.4% · Q3 0.8% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.7% |
63.0%
28.3 pts worse
|
79.7%
45 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
26.2%
1.2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 24.7% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
16 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
23 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-11-21
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
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 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-26
E · Potential for more than minimal harm
2024-11-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-01-26
F · Potential for more than minimal harm
2023-12-20
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-20
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-02-07
E · Potential for more than minimal harm
2023-12-20
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 2024-02-01
E · Potential for more than minimal harm
2023-12-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-01-25
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-25
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-03-30
F · Potential for more than minimal harm
2023-01-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
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 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-30
Inspection history
Recent health citations
G · Actual harm
2025-09-16
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 2025-10-10
D · Potential for more than minimal harm
2025-07-16
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 2025-07-18
G · Actual harm
2025-07-02
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 2025-07-18
D · Potential for more than minimal harm
2025-05-14
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 2025-05-22
G · Actual harm
2025-04-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-02-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-21
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 2025-03-07
G · Actual harm
2024-11-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-21
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 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
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 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
G · Actual harm
2024-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-05
G · Actual harm
2024-10-02
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 2024-10-11
D · Potential for more than minimal harm
2024-08-28
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 2024-09-05
D · Potential for more than minimal harm
2024-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-04-18
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 2024-05-03
D · Potential for more than minimal harm
2024-04-16
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-02
G · Actual harm
2024-02-29
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 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-13
E · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-20
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-06
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 2023-12-15
G · Actual harm
2023-10-10
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 2023-10-25
D · Potential for more than minimal harm
2023-06-21
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-06-29
J · Immediate jeopardy
2023-05-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-22
F · Potential for more than minimal harm
2023-05-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-22
G · Actual harm
2023-01-25
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 2023-02-22
F · Potential for more than minimal harm
2023-01-25
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 2023-02-22
E · Potential for more than minimal harm
2023-01-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-22
E · Potential for more than minimal harm
2023-01-25
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 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-02-22
Penalties and ownership
What sits behind the stars
$48,620
2025-04-30
Fine
Fine · fine $48,620
Fine
$40,339
2024-11-07
Fine
Fine · fine $40,339
Fine
$13,910
2024-10-02
Fine
Fine · fine $13,910
Fine
$14,050
2024-02-29
Fine
Fine · fine $14,050
Fine
$13,258
2023-10-10
Fine
Fine · fine $13,258
Fine
$33,982
2023-05-24
Fine
Fine · fine $33,982
Fine
$0
2023-05-24
Payment Denial
Payment Denial · denial start 2023-06-22 · 7 days
7 day denial
Ownership
Black, Terri
Corporate Director · Individual
Black, Terri
W-2 Managing Employee · Individual
Kanev, Leo
Contracted Managing Employee · Individual
Lutheran Home For The Aged
Operational/Managerial Control · Organization
Parks, Paula
Corporate Officer · Individual
Wagner, Tammy
W-2 Managing Employee · Individual
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