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 Lutheran Retirement Home during CMS and state inspections, most recent first.
Improper Jewelry Worn During Food Preparation and Service: A cook was observed prepping and serving meals while wearing multiple rings on 8 fingers and bracelets on both wrists. The same jewelry was worn during repeated kitchen tasks, and the cook acknowledged she knew she wore more jewelry than allowed. The Dietary Mgr stated staff may only wear a plain wedding band, and the facility policy and FDA Food Code limited jewelry during food prep.
A resident with severe cognitive impairment and total care needs had a right heel pressure ulcer, but ordered wound care and weekly documentation were not consistently completed as directed. The chart showed Betadine and Mepilex were given on bath days, a weekly wound measurement was missing, and the wound later deteriorated after a period of improvement. Staff interviews confirmed the treatment process and that the DON expected orders to be followed as written.
Failure to supervise a fall-risk resident in the shower room resulted in an unwitnessed fall. The resident had severe cognitive impairment, Alzheimer disease, unsteady gait, a history of falls, and required substantial to maximal assistance for transfers and toileting. Staff left the resident alone to retrieve a lift, and when they returned the resident was found on the floor in front of his wheelchair with the alarm sounding.
The facility failed to have the minimum required members present at QAA meetings. Review of sign-in sheets showed the July and October quarterly meetings did not include the DON, and the Administrator stated the meetings were not rescheduled when the DON was unavailable. The facility policy stated the quality assurance team would meet quarterly with the Medical Director, but it did not define the team members.
A resident with intact cognition reported a missing sweatshirt, but the facility failed to promptly resolve the grievance or complete a grievance form as per policy. Staff did not follow the grievance procedure for the missing item, which was of sentimental value, and the administrator confirmed the oversight.
A resident with severe cognitive impairment and joint disorders did not receive prescribed hand treatments to prevent contractures, as observed on multiple occasions. Staff interviews revealed a lack of adherence to physician orders, with incorrect transcription and failure to notify the physician of treatment issues. The facility policy required following physician orders, which was not done.
A resident with dental caries and a broken tooth did not receive necessary dental services since admission to the facility. Despite the resident's request for dental care, staff cited insurance issues and difficulty finding a provider as barriers. The facility's policy required assistance with dental care, but this was not provided.
The facility failed to provide bed hold notices to two residents during their hospital transfers, as required by policy. One resident was cognitively intact, while the other had moderate cognitive impairment. The DON confirmed the lack of bed hold notifications, despite the facility's policy mandating them upon transfer.
A facility failed to protect a cognitively impaired resident from sexual abuse by another resident with intact cognition who exhibited sexually aggressive behavior. Despite multiple incidents of inappropriate touching, the facility did not implement effective interventions or separate the residents in a timely manner. The lack of documentation, communication, and monitoring contributed to the deficiency, resulting in repeated exposure to inappropriate behavior for the vulnerable resident.
A male resident with intact cognition made inappropriate sexual advances towards a female resident with severely impaired cognition, involving touching without consent. The facility failed to report these incidents to the Department of Inspections, Appeals, and Licensing (DIAL) in a timely manner, resulting in an immediate jeopardy situation. Staff initially perceived the interactions as friendly gestures, but they escalated to inappropriate touching, which was not reported or investigated as required by facility policy.
A facility failed to investigate allegations of abuse and separate a resident with behavioral symptoms from another resident, leading to multiple incidents of inappropriate touching. Despite interventions like 15-minute checks and moving one resident to a memory care unit, the facility lacked documentation and did not ensure separation, resulting in an immediate jeopardy situation.
A facility failed to recognize a resident as a victim before transferring them to a different unit instead of their alleged abuser. The resident, with severely impaired cognition and Alzheimer's disease, was inappropriately touched by another male resident. The facility moved the victimized resident to a locked Alzheimer's wing, rather than relocating the alleged abuser, with the family's consent. This action did not prioritize the resident's right to a dignified existence and self-determination, as outlined in the Resident Rights brochure.
Improper Jewelry Worn During Food Preparation and Service
Penalty
Summary
The facility failed to prevent the risk of cross contamination from jewelry worn by a cook while meal prepping and serving food. On 2/23/26 at 10:20 AM, Staff D was observed in the kitchen preparing the meal while wearing multiple rings on 8 fingers and bracelets on both wrists. At 12:20 PM the same staff member was observed serving the noon meal while still wearing the same jewelry. On 2/24/26 at 11:00 AM Staff D was observed pureeing pork chops, sweet potatoes, and broccoli for the noon meal while continuing to wear rings on 8 fingers, including multiple rings on some fingers, and bracelets on both wrists. At 12:00 PM Staff D was again observed serving the noon meal with the same jewelry. At 12:30 PM, Staff D stated she knew she wore more jewelry than she should based on the regulations and policy. At 1:00 PM, the Dietary Manager reported staff cannot wear jewelry except a plain wedding band when working in the kitchen. The facility policy titled Employee Sanitary Practices dated 2005 directed staff to keep jewelry to a minimum of wedding rings, plain watches, and no dangle earrings, and the Food Code Manual January 18, 2023, Version documented that jewelry is prohibited except for a plain ring such as a wedding band while preparing food.
Pressure Ulcer Treatment and Monitoring Not Followed as Ordered
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with severe cognitive impairment who required total assistance with toileting, dressing, transfers, and repositioning. The resident had a right heel pressure ulcer, and the care plan revised on 2/25/26 directed staff to carry out skin treatments per orders and complete weekly treatment documentation with measurements, tissue type, exudate, and other notable changes. The physician’s progress note on 1/7/26 ordered daily Betadine to the right heel and application of a foam border dressing, and the February 2026 TAR listed Mepilex to the right heel on shower days and povidone-iodine solution 10% once daily. The documentation showed the resident received the Mepilex and iodine treatments on bath days, and the wound record reflected measurements on 1/28/26, 2/2/26, 2/11/26, and 2/24/26, with the wound described as improving until 2/24/26, when it was documented as deteriorating. The chart lacked a wound measurement for the week of 2/18/26. Staff interviews indicated the heel was painted with Betadine on shower days and covered with a foam dressing, and that the resident wore Podus boots at all times. The DON stated staff were expected to follow physician orders as written or notify the physician if treatment needed to change. The facility policy stated pressure sore documentation was to be completed weekly until resolved and the physician notified sooner than weekly with any decline.
Failure to Supervise a Fall-Risk Resident in the Shower Room
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a fall risk, resulting in an unwitnessed fall in the shower room. Resident #13 had a BIMS score of 6 out of 15 indicating severe cognitive impairment and required substantial to maximal assistance for transfers and toileting. The resident’s diagnoses included Alzheimer disease, anxiety, history of falling, and unsteady on feet. The care plan documented limited physical mobility, unsteadiness, a fall risk, dependence on staff for transfers and toileting, a pressure alarm at all times, and that the resident had fallen four times previously in the shower room. The incident report documented that the resident was in the shower room when the CNA left him unattended to retrieve a lift for assistance. Staff interviews confirmed that the resident was left alone in the shower room because the standing mechanical lift was not there, and when staff returned they heard the wheelchair alarm and found the resident on the floor in front of his wheelchair. The LPN and CNA who responded reported no staff were present when the resident was found, and the DON stated staff are not to leave residents unattended in the shower room at any time.
QAA Meetings Lacked Required DON Participation
Penalty
Summary
The facility failed to have the minimum required members present at Quality Assessment and Assurance (QAA) meetings to identify issues related to quality assessment and assurance activities. The facility reported a census of 36 residents. Review of QAA sign-in sheets showed that the July and October 2025 quarterly meetings did not include the DON. During an interview on 2/26/26 at 11:05 AM, the Administrator stated the DON did not attend those quarterly meetings because they were gone that day, and the meeting was not rescheduled so the DON could attend. The undated facility policy titled Quality Assurance Program stated that all staff members of the quality assurance team would meet quarterly with the Medical Director, but it did not define the quality assurance team members.
Failure to Resolve Grievance for Missing Property
Penalty
Summary
The facility failed to provide prompt efforts to resolve a grievance and did not complete a grievance form for a missing item reported by a resident. The resident, who had intact cognition as indicated by a BIMS score of 15, reported a missing black sweatshirt with an emblem, which was of sentimental value as it was a gift from family members. Despite reporting the missing item three weeks prior, the resident had not received any follow-up from the staff regarding the resolution of the grievance. Staff interviews revealed that the process for handling missing items involved searching other residents' rooms and notifying social services if the item was not found. However, the social services staff did not complete a grievance form for the missing sweatshirt, as they typically only did so for items deemed valuable, such as wallets or rings. The facility's grievance policy required that all missing property be reported and, if not immediately resolved, be followed up with a grievance procedure. The administrator confirmed that a Lost and Found report was completed, but not a grievance intake form, which was against the facility's policy.
Failure to Follow Physician Orders for Resident's Hand Care
Penalty
Summary
The facility failed to follow physician orders for a resident with severe cognitive impairment, joint disorder, depression, arthritis, and anxiety. The physician's orders required a palm grip to be applied to the resident's right hand at all times when in bed to prevent contractures, and a tubi grip to the left hand daily to reduce moisture and prevent injury. However, observations on multiple occasions revealed that the resident was in bed without the prescribed palm grip and tubi grip. The clinical record lacked documentation of any notification to the physician regarding the failure to implement these treatments or any reports of pain from the resident during treatment. Interviews with staff revealed a lack of adherence to the physician's orders. A CNA reported that only nurses handled the resident's hand treatments, while an LPN incorrectly stated that a tubi grip was applied to the right hand. The DON admitted that the orders were transcribed incorrectly on the Treatment Administration Record, leading to the assumption that the treatments were not performed. An RN reported that attempts to place a washcloth in the resident's right hand were stopped due to complaints of pain, but the physician was not notified. The facility's policy required staff to follow physician orders as directed, which was not adhered to in this case.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide necessary dental services to a resident, identified as Resident #20, who had a diagnosis of dental caries and a broken front tooth. Despite the resident's intact cognition and expressed desire to see a dentist, the facility did not arrange for dental care since the resident's admission. The resident reported that their front tooth began chipping after an incident involving a transfer, and they had not seen a dentist since being admitted to the facility. The resident was unaware of how to access dental services or the payment options available. Interviews with staff revealed a lack of action in addressing the resident's dental needs. Staff A, a CNA, was informed of the chipped tooth but did not observe any breakage and passed the information to Staff B, an LPN, who also did not see signs of chipping. Social Services staff cited insurance issues and difficulty finding a provider as barriers to obtaining dental care for the resident. The Director of Nursing mentioned that in emergency situations, the emergency room could provide temporary management. The Administrator was unaware of any dental options explored for the resident and planned to consult with the resident's family for potential solutions. The facility's policy indicated that nurses should assist with dental care and Social Services should help with reimbursement applications, but these actions were not taken for Resident #20.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a bed hold notice to two residents during their transfer to a hospital, as required by policy. Resident #7, who was cognitively intact with a BIMS score of 15, was discharged to the hospital on 5/28/24 and returned on a later date. The clinical records for Resident #7 lacked documentation of a bed hold notification being provided to the resident or their representative. Similarly, Resident #18, with a BIMS score of 9 indicating moderate cognitive impairment, was discharged to the hospital on 11/19/24 and returned on a later date. The facility's records also lacked documentation of a bed hold notification for Resident #18 or their representative. The Director of Nursing confirmed that the facility did not complete a bed hold for the hospitalizations of both residents, despite the facility's Reserve Bed Policy requiring such notification upon transfer.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to provide an environment free from sexual abuse for residents who lacked the mental capacity to consent to sexual contact. This deficiency involved two residents: one with severely impaired cognition and another with intact cognition but exhibiting sexually aggressive behavior. The cognitively impaired resident required total assistance with daily activities and was diagnosed with Alzheimer's disease and non-Alzheimer's dementia. The other resident, who was cognitively intact, displayed inappropriate behaviors such as touching and fondling the cognitively impaired resident on multiple occasions. Despite the occurrence of inappropriate touching incidents on several occasions, the facility did not implement effective interventions to prevent further incidents. The first incident occurred in the common area, where the cognitively intact resident fondled the other resident. The facility failed to separate the two residents after the first and second incidents and did not update the care plan or implement interventions until after the incidents had occurred. The facility's lack of timely and adequate response to these incidents resulted in a failure to protect the cognitively impaired resident from sexual abuse. The facility's documentation and communication regarding the incidents were also inadequate. There was a lack of incident reports and investigations related to the incidents, and staff interviews revealed that some staff members were unaware of the incidents or the need to implement interventions. The facility's failure to monitor the residents' locations as indicated and the absence of a communication book for staff contributed to the deficiency. This lack of action and oversight led to a situation where the cognitively impaired resident was repeatedly exposed to inappropriate behavior, highlighting a significant lapse in the facility's duty to protect its residents.
Failure to Report Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Inspections, Appeals, and Licensing (DIAL) after a male resident was observed making inappropriate sexual advances towards a female resident on multiple occasions. The incidents involved the male resident placing the female resident's hand inside his bib overalls and putting his hand down her shirt. These actions were observed on several dates, but the facility did not report the incidents to DIAL until later dates, resulting in an immediate jeopardy situation. Resident #1, a female with severely impaired cognition due to Alzheimer's disease and non-Alzheimer's dementia, was unable to consent to the interactions. She required total assistance with daily activities and used a wheelchair for mobility. Resident #2, a male with intact cognition and a history of behavioral symptoms, was independent in daily activities and used a walker. Despite his cognitive abilities, he continued to intrude on the privacy of others and engage in inappropriate behaviors towards Resident #1. Staff interviews revealed that the incidents were initially perceived as friendly gestures between the two residents, who were former neighbors. However, the interactions escalated to inappropriate touching, which was not immediately reported or investigated by the staff. The facility's policy required immediate reporting of abuse allegations, but the staff failed to follow these procedures, leading to a delay in addressing the situation and protecting the residents involved.
Failure to Investigate and Separate Residents Leads to Immediate Jeopardy
Penalty
Summary
The facility staff failed to thoroughly investigate allegations of abuse and did not separate a possible abuser from other residents, leading to an immediate jeopardy situation. The facility lacked documentation of thorough investigations and failed to conduct resident and staff interviews to determine the extent of the allegations. The facility did not separate the two residents involved until the incident occurred a third time, and the family had to request action. Resident #1, who had severely impaired cognition and required total assistance with daily activities, was inappropriately touched by Resident #2 on multiple occasions. Despite being notified of the incidents, the facility did not document any incident reports or investigations related to these events. The care plan for Resident #1 included interventions such as 15-minute checks and moving her to a locked memory care unit, but there was no documentation to keep the male resident away from her. Resident #2, who had intact cognition and exhibited behavioral symptoms directed toward others, was involved in several incidents of inappropriate touching. The facility's care plan for Resident #2 included monitoring behaviors and providing close supervision, but it lacked direction to keep him separated from Resident #1. The facility failed to ensure Resident #2 stayed away from Resident #1 following the first incident, allowing further incidents to occur before staff intervened.
Failure to Protect Resident's Rights and Dignity
Penalty
Summary
The facility failed to recognize a resident as a victim prior to transferring them to a different unit, instead of their alleged abuser. This deficiency involved a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 5, and diagnoses of Alzheimer's disease and non-Alzheimer's dementia. The resident required total assistance with toileting hygiene and transfers, did not walk, and used a wheelchair for mobility. The incident involved another male resident inappropriately touching the resident, which was reported to the resident's family and documented in the facility's records. The facility's response to the incident included moving the victimized resident to a different area within the facility, specifically a locked Alzheimer's wing, rather than relocating the alleged abuser. This action was taken with the family's consent, but it failed to prioritize the resident's right to a dignified existence and self-determination. The facility's records indicated that the resident did not exhibit immediate changes in mood, anxiety, or affect following the incident, and when asked about her feelings, she expressed concerns unrelated to the incident. The facility's documentation and staff interviews revealed that the resident's family was informed of the incident and the subsequent room change. However, the decision to move the resident rather than the alleged abuser suggests a failure to adequately protect the resident's rights and dignity. The facility's actions were not aligned with the resident's rights to be treated with respect and dignity, as outlined in the undated Resident Rights brochure.
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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 Northwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manly Specialty Care | 11.6 mi | ★★★★★ | 7 | 0 |
| Thorne Crest Retirement Center | 15.8 mi | ★★★★★ | 26 | 0 |
| Good Samaritan - Saint Ansgar | 16.3 mi | ★★★★★ | 0 | 0 |
| St Johns On Fountain Lake | 17.5 mi | ★★★★★ | 15 | 0 |
| Sacred Heart Care Center | 18.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.