Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Strawberry Point Lutheran Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and no prior exit-seeking behaviors was able to leave the facility unsupervised by following an employee out through a door with a delayed alarm, which did not sound at the time. The resident was later found outside by a staff member and returned safely, with no injuries identified.
A resident with moderate cognitive loss and multiple comorbidities was inaccurately coded on the MDS as having experienced two falls with major injuries, despite fall reports, EHR review, and staff interviews confirming no such injuries occurred.
A resident with multiple terminal diagnoses, including heart failure and cancer, experienced a change in condition when their cholecystostomy tube was found dislodged. The facility failed to document the incident or notify management promptly, as required by policy. The resident was transferred to a hospital but was not admitted, and the lack of timely intervention and documentation potentially contributed to the resident's decline.
The facility failed to complete a significant change MDS within the required 14-day period for two residents admitted to hospice care. One resident's MDS was completed 21 days after the change, and another's was completed 18 days after. The MDS nurse works remotely and visits the facility infrequently, and there is no formal policy for MDS completion, contributing to the delays.
A facility failed to document non-pharmacological interventions before administering as-needed anti-anxiety medication to a resident with dementia and depression. The care plan lacked specific directions, and multiple instances were noted where medication was given without documented interventions. Staff interviews revealed awareness of the need for interventions, but documentation was inconsistent. The facility's policy did not provide clear guidance on documenting these interventions.
The facility failed to use a clean barrier and properly sanitize blood glucose meters for two residents with diabetes, as observed during routine checks. Staff placed meters directly on bedside tables without barriers and did not clean them according to policy or manufacturer's guidelines. Interviews revealed a lack of training and awareness among staff, including the DON, regarding proper procedures for infection control.
A facility failed to provide the SNF ABN notice to a resident or their legal representative within 48 hours of ending Medicare Skilled Part A therapy services. The resident was discharged from therapy services but remained in the facility. The DON, responsible for serving beneficiary notices, was unfamiliar with the SNF ABN form and did not provide it. Documentation showed the transition to private pay but lacked evidence of the SNF ABN notice being issued.
Resident Elopement Due to Delayed Door Alarm and Unnoticed Exit
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a BIMS score of 9 and diagnoses including Wernicke's encephalopathy and cognitive communication deficit, was able to exit the facility unsupervised. The resident was last seen by staff visiting another resident and was later observed outside the facility by a staff member driving by, who then notified facility staff. The resident stated that someone held the door open for her, and the facility determined that she likely followed an employee out of the locked unit. At the time of the incident, the door alarm system had a 10-second delay before sounding, and the alarm did not activate during the event. The resident had no prior history of exit-seeking behaviors and was independent in mobility and activities of daily living. The facility's daily door checks had not previously identified any issues with the alarm system, and staff were unaware that the resident had exited until notified by the staff member outside. The resident was found outside in appropriate clothing for the weather and was assessed to have no injuries upon return. The facility's investigation concluded that staff acted according to existing policy, and the elopement was not preceded by any behavioral changes or warning signs from the resident.
Inaccurate MDS Coding for Falls with Major Injury
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident reviewed for falls with major injury. The MDS assessment indicated that the resident had experienced two falls with major injuries since the prior assessment, despite a review of unwitnessed fall reports and electronic healthcare records showing no documentation of any major injuries from falls during the relevant period. Staff interviews, including those with the DON and an LPN, confirmed that there was no knowledge or evidence of major injuries resulting from falls for this resident. The resident in question had a moderate cognitive loss, bilateral lower body functional impairment, and required assistance for mobility and transfers. The MDS listed several active diagnoses, including type two diabetes mellitus with neuropathy, anemia, arthritis, thyroid disorder, and non-Alzheimer's dementia. Despite these conditions, all available documentation and staff interviews indicated that the resident had not sustained any major injuries from falls, suggesting the MDS was inaccurately coded regarding falls with major injury.
Failure to Timely Address Change in Condition for Resident with Cholecystostomy Tube
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who experienced a change in condition. The resident, who had multiple diagnoses including renal insufficiency, PTSD, cancer, anemia, and heart failure, was receiving hospice services due to a terminal prognosis. The resident's care plan did not address the presence of a cholecystostomy tube, which was supposed to be managed according to physician's orders. On a specific date, staff failed to change the cholecystostomy dressing as scheduled, and later discovered that the cholecystostomy tube was dislodged, with no documentation on how or when this occurred. The incident was discovered when staff found the resident's cholecystostomy tube and bag not in place, with the bag hanging on the bed rail and the tubing next to the resident. Despite the facility's policy requiring immediate notification of the DON and Administrator for unscheduled removal of external devices, staff did not document the incident in the progress notes or notify management promptly. The resident was transferred to a hospital for evaluation, but the hospital did not admit the resident, advising instead to follow up with a surgical consult. The facility's internal investigation revealed that staff had observed the tubing out of place during the night but did not take appropriate action or notify the on-call staff. The facility's policy required immediate notification of significant changes in a resident's condition, but this protocol was not followed. The lack of documentation and timely intervention potentially contributed to the resident's decline, although the resident was already experiencing terminal health issues.
Failure to Timely Complete Significant Change MDS for Hospice Admissions
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) within the required 14-day period for two residents who were admitted to hospice care. Resident #4 was admitted to hospice on December 4, 2023, but the MDS was not completed until December 25, 2023, which is 21 days after the significant change was noted. Similarly, Resident #15 had a hospice consult and potential admission ordered on February 23, 2024, but the MDS was not completed until March 12, 2024, 18 days after the significant change was noted. The RAI manual specifies that a significant change MDS must be completed no later than the 14th calendar day after determining a significant change in resident status. The MDS nurse, who works remotely and visits the facility approximately every three months, stated that she follows the RAI manual guidelines for MDS completion but does not have any specific policies for completing the MDS. The Director of Nursing (DON) also confirmed that the facility does not have a policy for MDS completion and relies on the RAI manual guidelines. This lack of a formal policy and the remote working arrangement of the MDS nurse contributed to the delay in completing the MDS assessments for the residents experiencing significant changes in their condition.
Failure to Document Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to document the implementation of non-pharmacological interventions before administering as-needed anti-anxiety medication to a resident. The resident, who had a BIMS score indicating intact cognition, was diagnosed with unspecified dementia and depression and was prescribed Lorazepam for anxiety/restlessness. The care plan lacked specific directions for staff on interventions to try before administering the medication. A review of the resident's medication administration records and progress notes revealed multiple instances where Lorazepam was administered without documentation of non-pharmacological interventions being attempted. Behavioral progress notes were either missing or lacked documentation of interventions offered to reduce the resident's anxiety. Staff interviews indicated that while CNAs and nurses were aware of the need for interventions, there was a lack of consistent documentation in the electronic health records. The facility's policy on psychoactive drugs did not provide clear guidance on the implementation and documentation of non-pharmacological interventions. Interviews with staff, including the DON and LPN, confirmed that interventions should be documented before administering as-needed medications, but this was not consistently done. The facility's Quality Assurance and Process Improvement Program was noted to monitor outcomes, but the policy lacked specific directions for staff on documenting interventions.
Infection Control Deficiency in Blood Glucose Monitoring
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not utilizing a clean barrier under a blood glucose meter and not sanitizing the meter according to the facility policy and manufacturer's directions. This deficiency was observed in two residents, both of whom had diabetes mellitus and required regular blood glucose monitoring. During observations, it was noted that the blood glucose meters were placed directly on bedside tables without a clean barrier, and the meters were not cleaned after use as per the manufacturer's recommendations. For Resident #6, the blood glucose meter was placed directly on the bedside table without a clean barrier, and after use, it was stored without being sanitized. Staff A, who performed the procedure, confirmed that she did not clean the meter, assuming that the night shift staff handled the cleaning. However, upon reviewing the Glucose Control Testing Log, there was no indication that the meters were being cleaned as required. Similarly, for Resident #9, the blood glucose meter was placed partially on a disposable glove and partially on the bedside table, and after use, it was not properly sanitized before being stored. Interviews with Staff A and the Director of Nursing (DON) revealed a lack of awareness and training regarding the facility's policy and the manufacturer's recommendations for cleaning the blood glucose meters. Staff A admitted to not receiving any retraining or being familiar with the facility's policy on using a clean barrier and cleaning the meters. The DON also acknowledged not being aware of the manufacturer's guidelines and the need to update their information. The facility's Blood Sugar Monitoring Policy and the Infection Control Program Policy were not being followed, leading to the observed deficiencies.
Failure to Provide SNF ABN Notice
Penalty
Summary
The facility failed to provide the Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident or their legal representative within 48 hours of the ending of Medicare Skilled Part A therapy services. Resident #69 was admitted to Medicare Part A Skilled services and later discharged from these services while remaining in the nursing facility. The therapy department communicated that the resident was not progressing and would be discharged from physical, occupational, and speech therapy. Although the resident's family was notified of the discharge and discussed the resident's care plan, the facility did not provide the required SNF ABN notice prior to the ending of Medicare Skilled services. The Director of Nursing (DON) was responsible for serving the beneficiary notices but was unfamiliar with the SNF ABN form. During an interview, the DON questioned if the wrong form was served and acknowledged that the SNF ABN had not been provided to the resident or the legal representative. The facility's Survey Readiness Binder contained documentation of the discharge from Medicare Skilled services and the transition to private pay, but it lacked evidence that the SNF ABN notice was given. The DON had trained with the Administrator and a nurse consulting agency on serving beneficiary notices, yet the required notice was not issued.
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Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Strawberry Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Convalescent Home | 7.4 mi | ★★★★★ | 3 | 0 |
| Elkader Care Center | 12.8 mi | ★★★★★ | 0 | 0 |
| Good Neighbor Home | 14.8 mi | ★★★★★ | 3 | 0 |
| Maple Crest Manor | 17.5 mi | ★★★★★ | 0 | 0 |
| Grandview Healthcare Center | 18.8 mi | ★★★★★ | 5 | 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.