Cycle 1
Health 2023-01-30 · Fire 2023-01-30
45 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
North Canton, OH
Saint Luke Lutheran Home
1-star overall rating with 1-star inspections with Special Focus status with $97,793 in total fines with 45 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
220 Applegrove Street Ne, North Canton, OH
(330) 499-8341
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
166
Certified beds
Average residents
130
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-06-12
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
0.39
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,608
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.37
Baseline 19.89% · Performance 19.41% · Measure score 4.37 · Achievement 4.37 · Improvement 1.18
Healthcare-associated infections
0
Baseline 5.62% · Performance 8.36% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 54.31% · Performance 67.44% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.88
Baseline 4.53 hours · Performance 4.47 hours · Measure score 4.88 · Achievement 4.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 4.65% · Lower 95% interval 6.23% |
| Discharge to community | 41.9% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 35.96% · Lower 95% interval 33.24% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.62% |
95.27%
0.6 pts worse
|
Numerator 88 · Denominator 93 |
| Falls with major injury | 2.15% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 93 |
| Discharge self-care score | 45.31% |
53.69%
8.4 pts worse
|
Numerator 29 · Denominator 64 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 36 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 93 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.36% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 5.14% |
| Staff COVID-19 vaccination coverage | 8.64% |
8.2%
0.4 pts better
|
Numerator 19 · Denominator 220 |
| Staff flu vaccination coverage | 18.01% |
42%
24 pts worse
|
Numerator 38 · Denominator 211 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 38 · Denominator 64 |
| Transfer of health information to provider | 93.33% |
95.95%
2.6 pts worse
|
Numerator 28 · Denominator 30 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 13.21% |
25.2%
12 pts worse
|
Numerator 7 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
92.4%
2 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 96.6% · Q3 95.5% · Q4 89.9% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.5%
3.9 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.7% |
3.3%
4.4 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.0% · Q3 8.2% · Q4 7.3% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.4% |
26.1%
8.7 pts better
|
11.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.6% · Q3 22.2% · Q4 23.2% · 4Q avg 17.4% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.2%
2.9 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 12.4% · Q3 6.7% · Q4 11.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
25.4%
1.2 pts better
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 25.8% · Q3 19.8% · Q4 27.0% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
11.5%
2.8 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 14.1% · Q3 14.1% · Q4 15.6% · 4Q avg 14.3% · 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 | 18.5% |
7.7%
10.8 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 12.1% · Q3 26.8% · Q4 18.3% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
6.2%
13.8 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 26.4% · Q3 19.3% · Q4 19.8% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.2%
About the same
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.5%
0.4 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
21.7%
11 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 34.9% · Q3 31.6% · Q4 38.9% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
3.7%
About the same
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.1% · Q3 1.7% · Q4 2.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.7% |
78.1%
15.4 pts worse
|
81.7%
19 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 70.9% · Q3 56.3% · Q4 47.1% · 4Q avg 62.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.5%
About the same
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 0.7% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.7% |
75.6%
0.9 pts worse
|
79.7%
5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
25.1%
0.7 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 23.5% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-06 · Fire 2020-02-06
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2019-01-16 · Fire 2019-01-16
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-05-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-25
F · Potential for more than minimal harm
2023-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-30
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 2023-03-07
E · Potential for more than minimal harm
2023-01-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-30
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-07
F · Potential for more than minimal harm
2020-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-09
F · Potential for more than minimal harm
2020-02-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2020-03-09
F · Potential for more than minimal harm
2020-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-09
E · Potential for more than minimal harm
2020-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-09
E · Potential for more than minimal harm
2020-02-06
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2020-03-09
E · Potential for more than minimal harm
2020-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-09
F · Potential for more than minimal harm
2019-01-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-02-19
F · Potential for more than minimal harm
2019-01-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-02-19
E · Potential for more than minimal harm
2019-01-16
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-02-19
E · Potential for more than minimal harm
2019-01-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-19
C · Minimal harm
2019-01-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-02-19
C · Minimal harm
2019-01-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-02-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-30
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 2026-02-13
D · Potential for more than minimal harm
2026-01-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-13
D · Potential for more than minimal harm
2026-01-05
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-01-13
D · Potential for more than minimal harm
2026-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-11-24
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 2026-01-05
D · Potential for more than minimal harm
2025-11-24
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-11-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-10-14
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 2026-01-05
F · Potential for more than minimal harm
2025-09-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-11
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 2025-09-25
D · Potential for more than minimal harm
2025-09-11
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 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-25
J · Immediate jeopardy
2025-08-04
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 2025-09-25
G · Actual harm
2025-08-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-08-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-08-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-08-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-08-04
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-08-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-08-04
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 2025-09-25
E · Potential for more than minimal harm
2025-08-04
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 2025-09-25
D · Potential for more than minimal harm
2025-08-04
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 2025-09-25
D · Potential for more than minimal harm
2025-08-04
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-04
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 2025-09-25
D · Potential for more than minimal harm
2025-08-04
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 2025-09-25
D · Potential for more than minimal harm
2025-08-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-04
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 2025-09-25
D · Potential for more than minimal harm
2025-08-04
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 2025-09-25
F · Potential for more than minimal harm
2025-05-12
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 2025-09-25
D · Potential for more than minimal harm
2025-05-12
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 2025-09-25
D · Potential for more than minimal harm
2025-05-12
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 2025-09-25
D · Potential for more than minimal harm
2025-05-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-25
C · Minimal harm
2025-05-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-03-10
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 2025-04-02
G · Actual harm
2023-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-30
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 2023-03-07
D · Potential for more than minimal harm
2023-01-30
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 2023-03-07
D · Potential for more than minimal harm
2023-01-30
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 2023-03-07
D · Potential for more than minimal harm
2023-01-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-30
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 2023-03-07
F · Potential for more than minimal harm
2020-02-06
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-03-09
E · Potential for more than minimal harm
2020-02-06
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 2020-03-09
E · Potential for more than minimal harm
2020-02-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
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 2020-03-09
D · Potential for more than minimal harm
2020-02-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
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 2020-03-09
D · Potential for more than minimal harm
2020-02-06
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 2020-03-09
D · Potential for more than minimal harm
2020-02-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-09
G · Actual harm
2019-01-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-02-19
F · Potential for more than minimal harm
2019-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-19
E · Potential for more than minimal harm
2019-01-16
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 2019-02-19
E · Potential for more than minimal harm
2019-01-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-02-19
E · Potential for more than minimal harm
2019-01-16
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 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
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 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
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 2019-02-19
D · Potential for more than minimal harm
2019-01-16
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 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-02-19
D · Potential for more than minimal harm
2019-01-16
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-02-19
Penalties and ownership
What sits behind the stars
$97,793
2025-05-12
Fine
Fine · fine $97,793
Fine
$0
2025-05-12
Payment Denial
Payment Denial · denial start 2025-08-12 · 44 days
44 day denial
Ownership
St. Luke Lutheran Community
5% Or Greater Direct Ownership Interest · Organization
Diehl, Diane
Corporate Director · Individual
Hessel, Robert
Corporate Director · Individual
Langer-Champlin, Kathleen
W-2 Managing Employee · Individual
Mcnulty, Andrew
Corporate Director · Individual
Mohler, Joyce
W-2 Managing Employee · Individual
Spieler, John
Corporate Officer · Individual
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