Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeside Lutheran Home during CMS and state inspections, most recent first.
The facility failed to ensure GDRs were completed or clinically justified for residents receiving psychotropic medications. One resident with anxiety disorder and cognitive impairment remained on Buspirone, Melatonin, and Olanzapine without a documented rationale for why GDR was contraindicated, and another resident with anxiety disorder, bipolar disorder, and PTSD remained on multiple psychotropics, including antipsychotics, antidepressant, and anticonvulsant therapy, without a documented rationale for no GDR after the pharmacist requested review.
A facility failed to accurately code the MDS for two residents. One resident’s MDS incorrectly indicated an indwelling urinary catheter even though the catheter had been discontinued and the resident was observed without one; the resident’s care plan reflected bladder incontinence and briefs instead. Another resident’s MDS incorrectly marked PASRR A1500 as “no” despite documentation showing a Level 1 positive screen with evidence of serious mental illness.
A resident with anxiety and depression, who was cognitively intact, reported that a bath-aide was rough during care, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. After the allegation, the aide was only reassigned to a different area and continued working with other residents before being suspended, contrary to facility policy requiring immediate separation of the accused from all residents.
Two residents with no cognitive impairment were not allowed to make choices about their bathing routines, clothing, and bedtime. Staff rushed one resident during bathing, refused to use the whirlpool jets, and did not allow her to wear jewelry, while another resident was made to go to bed early and wear a hospital gown against his wishes, and his input on CPAP use was ignored. These actions did not support resident self-determination as required by facility policy.
A resident with no cognitive impairment reported rough treatment by a CNA during a shower, including being pinched with a gait belt and having a toothbrush jammed into her mouth, resulting in pain and weakness. Although the DON was notified promptly, the physician and the resident's representative were not informed until two days later, failing to meet immediate notification requirements.
A resident with no cognitive impairment reported that a CNA was rough during a bath, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. Although the incident was documented and communicated to staff, the facility did not notify the state agency of the allegation within the required timeframe, as confirmed by the administrator.
A resident with cancer and mobility limitations, who required assistance and had fragile skin, sustained multiple skin tears on the right forearm when a CNA grabbed the wrist instead of using a gait belt during a transfer, contrary to the care plan and facility protocol.
A resident with severe cognitive impairment and high fall risk experienced a fall due to inappropriate footwear. The facility failed to conduct adequate follow-up and pain assessments, leading to a delayed diagnosis of a right femoral neck fracture. Despite signs of pain and mobility issues, the facility did not notify the physician of the fall history, and an x-ray was only ordered after a physical therapy evaluation.
The facility failed to submit accurate staffing data to CMS, as the PBJ report showed a lack of 24-hour nursing coverage on several dates. However, time card records and agency invoices indicated that 24-hour coverage was maintained, but this was not reflected in the PBJ report.
The facility failed to conduct proper background checks for a CNA and the DON, both of whom had a criminal history of operating while intoxicated. There was no documentation of a record check evaluation or approval to work from the Iowa Department of Human Services, yet both were actively working. The facility's abuse prevention policy lacked guidance on employee screening and background checks.
The facility failed to re-evaluate long-term antibiotic use for two residents, leading to potential overuse. One resident was on Cephalexin 500 mg daily for chronic UTIs without a physician's re-evaluation, and another resident missed a urology appointment necessary for monitoring their condition. The lack of oversight in antibiotic use and follow-up appointments indicates a deficiency in the facility's antibiotic stewardship program.
A resident with moderately impaired cognition and multiple diagnoses was improperly administered Fosamax along with other medications after breakfast, contrary to the manufacturer's instructions. The facility's MAR lacked specific directions for Fosamax, leading to its incorrect administration. The DON confirmed the medication should have been given on an empty stomach, with the resident remaining upright for 30 minutes afterward.
A resident with severely impaired cognition was verbally threatened by an RN during a blood sugar check. The RN raised her hand as if to strike the resident and made a threatening statement. Multiple staff members witnessed or were informed of the incident, but it was not immediately reported. The facility suspended the RN pending investigation, revealing a failure in abuse prevention and reporting procedures.
A facility failed to timely report an alleged abuse incident involving a resident and an RN. The incident, witnessed by a CNA, involved the RN raising her hand and verbally threatening the resident during a blood sugar check. Despite the CNA reporting the incident to the DON, the facility only initiated an investigation after being informed by DIAL. The facility's internal investigation lacked police notification, as required by policy.
A facility failed to respond appropriately to an alleged abuse incident involving a resident and an RN. The RN threatened a resident after an altercation, but the incident was not reported or investigated until external authorities intervened. The RN continued working without suspension, contrary to facility policy.
Failure to Document GDR Rationale for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had a Gradual Dose Reduction (GDR) unless clinically contraindicated. For one resident with anxiety disorder and moderate cognitive impairment, the record showed ongoing use of Buspirone 10 mg three times daily, Melatonin 10 mg daily, and Olanzapine 10 mg daily. A pharmacist letter asked the physician to review the medications and specifically inquired about GDR for these drugs, but the clinical record did not contain a rationale explaining why a GDR for the psychotropic medications was contraindicated. The DON stated that melatonin had been decreased after hospitalization, but the antianxiety medication had not been addressed, and the facility did not have a psychotropic medication policy. For another resident with anxiety disorder, bipolar disorder, and PTSD, the record showed use of multiple psychotropic medications, including Perphenazine, Trazodone, Risperidone, Divalproex, and Quetiapine. The care plan identified these medications as related to behavior management and mental health diagnoses, and the pharmacist again asked the physician to review the medications and consider GDRs. The provider responded that there were no changes, but no rationale was documented for not reducing the psychotropic medications. The DON confirmed that the provider did not provide a rationale for no GDR on the psychotropic medications.
Inaccurate MDS Coding for Catheter Status and PASRR
Penalty
Summary
The facility failed to complete the MDS assessment accurately for 2 of 13 residents reviewed. For Resident #19, the MDS dated [DATE] scored a 6 on the BIMS, indicating severe cognitive impairment, and documented an indwelling urinary catheter. However, on 2/23/26 at 3:30 p.m., the resident was observed sitting in a recliner with no catheter present. The care plan identified mixed bladder incontinence related to diuretic therapy and included use of disposable briefs, but it did not document a catheter. Record review showed the resident had been admitted skilled after right hip fracture repair with a catheter, an order to discontinue the catheter was received on 9/15/25, the catheter was removed that day, and the resident was documented voiding without concerns after removal on 9/16/25. The MDS Coordinator stated she marked the MDS incorrectly regarding the catheter, and the Administrator stated the MDS should be coded accurately. For Resident #31, the MDS assessment dated [DATE] marked “no” to A1500, indicating the resident was not considered by the state level 2 PASRR process to have serious mental illness. However, a Notice of PASRR Level 1 Screen Outcome dated 11/8/23 documented the resident as Level 1 positive with no status change and showed evidence of a serious mental illness. The notice stated the services identified in the previous PASRR remained appropriate, and because the evaluation determined the resident had a PASRR condition, the MDS should have been coded “yes” for A1500. The Social Services Supervisor stated on 2/24/26 that Resident #31’s MDS was coded incorrectly regarding PASRR.
Failure to Immediately Separate Alleged Abuser from All Residents
Penalty
Summary
The facility failed to immediately separate an alleged abuser from all potential victims following an allegation of abuse. A resident with no cognitive impairment, who had diagnoses of anxiety and depression, reported that a bath-aide was rough and rushed her during a shower, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. The incident was reported to a charge nurse and the DON, but the staff member accused of abuse was only reassigned to a different area and continued to work with other residents before being suspended. The facility's abuse prevention policy requires immediate separation of the accused employee from all residents upon receiving an allegation, but this was not followed, resulting in a failure to protect all potential victims during the investigation.
Failure to Support Resident Choice in Daily Routines and Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choices regarding schedules, clothing, and bathing preferences for two residents. One resident, who had no cognitive impairment and required assistance with bathing, reported that a CNA was rough, rushed her during showers, and refused to use the whirlpool jets or allow her to wear her jewelry, stating she did not have time to accommodate these preferences. Documentation and staff statements confirmed that the CNA prioritized speed over resident choice due to pressure to complete baths quickly, resulting in the resident's preferences being disregarded. Another resident, also cognitively intact and dependent on staff for dressing and transfers, was made to go to bed at a set time and wear a hospital gown against his wishes. Staff did not listen to his requests regarding bedtime, clothing, or the correct use of his CPAP machine. Documentation included a disciplinary report and staff statements confirming that the resident's choices were not respected, and his attempts to communicate his preferences were ignored. The facility's own resident rights policy included the right to self-determination and making choices about significant aspects of life, which was not upheld in these instances.
Delayed Notification of Physician and Representative After Resident Allegation
Penalty
Summary
The facility failed to immediately notify the physician and the resident's representative after a resident reported an allegation of rough treatment by a CNA during a shower. The resident, who had no cognitive impairment and required substantial to maximal assistance with bathing, reported that her breast was pinched with a gait belt and a toothbrush was jammed into her mouth. She also complained of pain in her breast radiating to her back, weakness, and inability to walk. The incident was documented in the progress notes, and the DON was notified on the same day. Despite the immediate internal notification, the physician and the resident's representative were not informed of the allegation until two days later. Documentation shows that the physician was notified via fax and the family was contacted on the same day, both occurring after the initial report by the resident. The delay in external notification constitutes the deficiency, as the required parties were not informed immediately as per regulatory requirements.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) within the required timeframe after an allegation of potential abuse was made by a resident. The resident, who had no cognitive impairment and required substantial to maximal assistance with bathing, reported that a bath aide was rough during a shower, pinched her breast with a gait belt, and jammed a toothbrush in her mouth. The incident was documented in the resident's progress notes, and staff interviews confirmed that the resident communicated these concerns to another staff member. Despite the facility's policy requiring that all allegations of neglect, mistreatment, or abuse be reported to the state agency within two hours if serious bodily injury occurred, or within twenty-four hours otherwise, the administrator confirmed that the incident was not reported to DIAL in a timely manner. The delay in reporting was acknowledged during the investigation, and the facility's own policy was not followed in this instance.
Failure to Use Proper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use appropriate transfer techniques for a resident who required partial to moderate assistance with mobility due to weakness and cancer. The resident, who had no cognitive impairment and was care planned to have two staff assist with mobility and to avoid grabbing his arms due to fragile skin, sustained multiple skin tears on his right forearm after the CNA grabbed his wrist instead of using a gait belt during a transfer. The skin tears measured 4 cm by 1 cm, 2.5 cm by 1 cm, and 2 cm by 1 cm, with blood noted from each area. Documentation confirmed the incident and the CNA's violation of facility protocol.
Inadequate Follow-Up and Pain Assessment After Resident Fall
Penalty
Summary
The facility failed to provide adequate follow-up and pain assessments for a resident after a fall. The resident, who had severe cognitive impairment and was at a high risk for falls, experienced a fall while walking with staff. The incident report noted that the resident was wearing inappropriate footwear, which was not marked as a predisposing factor. Despite the resident's refusal to allow neurological assessments, the facility did not complete follow-up assessments or document the resident's condition adequately in the days following the fall. The resident began to exhibit signs of pain and difficulty with mobility, which were not immediately addressed by the facility. Progress notes indicated that the resident complained of right leg pain and showed signs of discomfort, such as facial grimacing and a limp. Despite these observations, the facility did not notify the physician of the resident's fall history when communicating about the resident's condition. It was only after a physical therapy evaluation that an x-ray was ordered, revealing a right femoral neck fracture. Interviews with staff revealed a lack of consistent documentation and follow-up after the fall. The Director of Nursing and MDS Coordinator acknowledged that the facility did not conduct an internal investigation into the resident's hip fracture and failed to adhere to the facility's fall policy, which required thorough documentation and communication with the physician. The facility's policy outlined specific steps for immediate response and follow-up after a fall, which were not followed in this case.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for fiscal year quarter 4 of 2024. The Payroll Based Journal (PBJ) Staffing Data Report indicated that the facility did not have licensed nursing coverage 24 hours a day on multiple dates in July, August, and September 2024. However, the facility provided time card records and agency staffing invoices that documented 24-hour nursing coverage on those dates. Despite this documentation, the information was not accurately reported in the PBJ report, leading to a deficiency finding.
Failure to Conduct Proper Employee Background Checks
Penalty
Summary
The facility failed to conduct appropriate screening prior to employment for two out of five employees reviewed for background checks. Specifically, the personnel files for a Certified Nursing Assistant (CNA) and the Director of Nursing (DON) showed that both had a criminal history of operating while intoxicated, 1st offense. Despite this, there was no documentation in their files indicating that a record check evaluation was conducted or that approval to work was obtained from the Iowa Department of Human Services. Both employees were actively working at the facility at the time of the survey. The facility's administrator acknowledged the absence of documentation approving the employees to work and admitted that the facility's abuse policy did not address the screening of new employees or the completion of background checks. The Business Office Manager confirmed that no further action was taken after receiving the criminal background check history. The facility's existing abuse prevention policy, revised in April 2017, did not include guidance on screening new employees or conducting background checks, which contributed to the deficiency.
Failure to Re-evaluate Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure that residents on antibiotics were re-evaluated for excessive duration, specifically for two residents. Resident #7, who had a history of chronic urinary tract infections, was on a routine antibiotic therapy with Cephalexin 500 mg daily since April 2022. The resident's clinical record lacked documentation of a physician's re-evaluation for the continued use of the antibiotic. The Pharmacy Consultant noted that the prophylactic dose is usually lower, and the Infection Preventionist confirmed that the antibiotic had not been reviewed in the past year. Resident #7 was unaware of the medications she was taking, indicating a lack of communication and oversight in her care plan. Resident #6, with diagnoses including anxiety, schizophrenia, seizure disorder, and heart failure, was also on prophylactic antibiotic therapy due to a history of frequent urinary tract infections. The resident was supposed to have a urology appointment, which did not occur, and the Director of Nursing was unsure of the reason. This lack of follow-up and re-evaluation of antibiotic use highlights a deficiency in the facility's antibiotic stewardship program, potentially leading to unnecessary or inappropriate antibiotic use.
Improper Administration of Fosamax
Penalty
Summary
The facility failed to administer medications according to the manufacturer's instructions for one resident during a medication pass. The resident, who had moderately impaired cognition and diagnoses including cerebral palsy, non-Alzheimer's dementia, seizures, and moderate intellectual disabilities, was observed receiving Fosamax along with other medications after breakfast. The manufacturer's instructions for Fosamax require it to be taken with plain water at least 30 minutes before any food, drink, or other medications, and the resident should remain upright for at least 30 minutes after taking it. The Certified Medication Aide (CMA) administered the Fosamax along with several other medications, including Levothyroxine, Calcium Carbonate, and Ferrous Sulfate, which could interfere with Fosamax's absorption. The facility's Medication Administration Record (MAR) lacked specific instructions on how Fosamax should be administered, leading to its improper administration. The Director of Nursing (DON) confirmed that the medication should have been given on an empty stomach and with the resident sitting upright for 30 minutes afterward. The facility's policy on medication disbursement emphasized the importance of following special instructions, which was not adhered to in this case.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a staff member. Resident #24, who has severely impaired cognition and is dependent on staff for various activities, was involved in an incident where a staff member, Staff B, RN, verbally threatened the resident. The resident, who has a history of physical and verbal behavioral symptoms, attempted to bite Staff B during a routine blood sugar check. In response, Staff B raised her hand as if to strike the resident and verbally threatened to knock the resident's teeth out. Multiple staff members witnessed or were informed of the incident. Staff A, CNA, was present in the room and intervened by calming the resident, allowing Staff B to complete the blood sugar check. Staff A later reported that Staff B recounted the incident at the nurses' station, repeating the threatening statement. Staff C, CMA, also provided a statement about a similar previous incident involving Staff B, indicating a pattern of inappropriate behavior and frustration management issues. The facility's policy on abuse prevention and reporting was not adequately followed, as the incident was not immediately reported by all staff who were aware of it. The Director of Nursing and the Administrator were informed of the allegations only after a state official reported the incident. The facility suspended Staff B pending investigation, but the delay in reporting and addressing the incident highlights a failure in the facility's procedures to protect residents from abuse.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged verbal and physical abuse incident involving a resident in a timely manner. The incident occurred when a CNA witnessed an RN raise her hand and verbally threaten a resident during a blood sugar check. The CNA reported the incident to the DON later that day, but the DON denied receiving any such report. The facility only initiated an investigation after the Department of Inspection, Appeals and Licensing (DIAL) entered the facility and informed the DON of the allegations. The investigation revealed that the incident took place in the resident's room, where the RN allegedly threatened to knock the resident's teeth out if he attempted to bite her. Multiple staff members were aware of the incident, but there was a delay in reporting it to the appropriate authorities. The facility eventually reported the incident to DIAL ten days after it occurred, and the RN was suspended pending investigation. The facility's internal investigation lacked documentation of police notification, which was required by their policy in cases of suspected abuse. The facility's policy mandates immediate reporting of abuse allegations to the state and law enforcement, but this was not followed. The DON and Administrator both stated they were unaware of the incident until DIAL's intervention, highlighting a breakdown in communication and adherence to reporting protocols.
Failure to Respond to Alleged Abuse Incident
Penalty
Summary
The facility failed to appropriately respond to an alleged incident of abuse involving a resident and a staff member. On the morning of January 6, 2025, a CNA witnessed a Registered Nurse (RN) threaten a resident with physical harm after the resident attempted to bite the RN. The CNA reported the incident to the Director of Nursing (DON) later that afternoon, but the DON denied being informed of the allegation. Despite the serious nature of the accusation, the RN continued to work full shifts on multiple days following the incident, indicating a failure to separate the accused staff member from residents pending an investigation. The facility's investigation into the alleged abuse was only initiated on January 16, 2025, after the Department of Inspections, Appeals and Licensing (DIAL) entered the facility and informed the DON of the complaint. Interviews with staff members revealed that the RN had a history of expressing frustration and making inappropriate comments, although there was no consensus on whether the RN had actually threatened the resident. The facility's policy required immediate suspension of the accused staff member and a thorough investigation, but these steps were not taken until prompted by external authorities. The delay in addressing the allegations and the continued presence of the RN in the facility without any immediate action to protect residents highlight significant lapses in the facility's abuse prevention and reporting procedures. The facility's failure to promptly investigate and report the incident to the appropriate authorities, as well as the lack of immediate protective measures, contributed to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Emmetsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palo Alto County Hospital | 0.4 mi | ★★★★★ | 0 | 0 |
| Emmetsburg Care Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Ruthven Community Care Center | 11 mi | ★★★★★ | 2 | 0 |
| West Bend Health And Rehabilitation | 16.2 mi | ★★★★★ | 0 | 0 |
| Laurens Care Center | 20.7 mi | ★★★★★ | 8 | 0 |
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