Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Nursing Home during CMS and state inspections, most recent first.
A facility failed to report a resident-to-resident altercation as suspected abuse according to its own policy and regulatory requirements. A resident with dementia and severe cognitive impairment exhibited aggressive behavior, including hitting another cognitively impaired resident, attempting to enter another resident’s room with family present, and attacking staff. An LPN documented the behaviors and notified the resident’s family and physician but did not clearly notify the administrator or DON, and no report was made to the state agency. Staff interviews showed that CNAs and LPNs understood that resident-to-resident altercations should be reported immediately, yet the administrator and DON stated they were never informed. The LPN later acknowledged sending a vague text to the DON describing the residents as having hit each other and being “grumpy old ladies,” expressed uncertainty about whether the event constituted abuse because there was no injury, and the incident was never formally reported as required.
The facility failed to investigate a resident-to-resident altercation involving a cognitively impaired resident with dementia and agitation who exhibited aggressive behaviors, including hitting another cognitively impaired resident, attempting to lock themself in another resident’s room while family was present, and attacking staff by punching, spitting, and attempting to bite. An LPN documented the incident and notified the resident’s son and physician, and staff acknowledged that abuse allegations require investigation by the Administrator. However, the DON and Administrator reported they were never informed of the altercation and no investigation, as required by the facility’s abuse and investigation policy, was initiated or completed.
A resident with a prosthetic heart valve and recent hospitalization for anticoagulation issues was admitted on warfarin 5 mg daily, but no INR lab orders were entered or completed despite hospital discharge instructions calling for an early INR check and weekly monitoring. The facility’s anticoagulation policy required identification of anticoagulated residents, review of recent labs, and close INR monitoring for those on warfarin. Staff interviews showed that the ADON, who was responsible for entering admission and lab orders into the EMR and lab system, did not enter INR orders and had since left employment, and there was no process to verify that all admission orders were in place. The DON confirmed that the resident had no INR testing during the stay, and the physician stated that all discharge instructions, including INR monitoring, were expected to be followed.
A resident with dementia and generalized anxiety disorder exhibited frequent and escalating aggressive behaviors, including hitting, kicking, spitting, using racial slurs, and attacking other residents and staff, often requiring 1:1 observation and extensive redirection. Despite these ongoing incidents, the resident’s behavior care plan and goals had not been updated for an extended period and continued to list only general interventions, while staff reported the resident was no longer easily redirectable and had increased aggression and restlessness. Behavioral monitoring orders were not initiated until months after aggressive behaviors were documented, and even after initiation, MAR/TAR entries frequently indicated no behaviors on days when progress notes and staff interviews described significant aggression, including an episode where the resident pulled a gate off its hinges and struck a nurse in the face. CNAs and nurses reported limited or no access to care plans, lack of education on managing behaviors, inconsistent documentation of behaviors, and a perception that management did not act on reported behaviors, resulting in inaccurate behavioral monitoring and an out-of-date care plan that did not reflect the resident’s current status or effective interventions.
Failure to Complete Required Quarterly EDL Checks: The facility failed to complete required quarterly EDL checks for 8 of 10 sampled employees. Records showed each employee had an initial EDL check at hire, but the required quarterly checks were not completed. The HR/BOM stated there were no records of quarterly checks and that checks were only done at hire, while the Administrator said the BOM was responsible and no one was monitoring completion.
A resident with a history of UTI, urinary incontinence, and dysuria had a UA/culture ordered after reporting burning with urination. The specimen was not picked up as expected, the lab could not locate the order or results, and staff had to obtain additional urine samples. Because of the delayed lab coordination, ABT did not start until several days later, and the final culture showed Proteus mirabilis over 100,000 CFU/ml.
Failure to ensure timely vision services for a resident with ESRD who used corrective lenses and reported poor vision without glasses. The resident missed an eye doctor visit because he/she was out at dialysis, and no follow-up appointment was scheduled afterward. Staff, including the SSD, BOM, CNA, LPN, ADON, and DON, were unaware the resident had missed the visit or was missing glasses, and the care plan did not address vision needs.
Inadequate care was provided for a resident with a G-tube who had a stroke, dysphagia, and severely impaired cognition. Observations showed the HOB was not consistently elevated as ordered and the tube feeding bag was not properly labeled with required information. Staff interviews showed inconsistent understanding of the required HOB angle and labeling, and leaders stated the resident was fully dependent on staff for positioning and that the care plan was not current.
Failure to identify PTSD triggers and provide trauma-informed supportive care: Two residents with PTSD had care plans and assessments that did not clearly identify triggers, staff responses, or supportive interventions. One resident’s chart showed PTSD and a history of abuse, but staff could not identify triggers and the care plan did not address them. Another resident had PTSD, anxiety, depression, and bipolar disorder, with trauma assessments noting nightmares, avoidance, and hypervigilance, yet the care plan lacked trigger details, a crisis intervention plan, and documentation of counseling services. Interviews showed the resident, family, and staff all described ongoing trauma-related concerns that were not reflected in the care planning.
Failure to ensure two NAs completed CNA training within the required four-month timeframe. Facility records showed both NAs had worked well beyond 4 months without documentation of CNA training, while the HR/BOM confirmed there was no paperwork showing they were CNAs and that they were still working as NAs. The DON and Administrator stated NAs must become CNAs within 16 weeks of hire, but the Administrator was not aware these two staff members had not met that requirement.
The facility failed to ensure appropriate follow-up on pharmacist-recommended GDRs for two residents receiving psychotropic medications. One resident was receiving multiple meds for MDD, anxiety, and restlessness/agitation, and another resident was receiving Rexulti for dementia with agitation. In both cases, the provider disagreed with the pharmacist’s GDR recommendation but did not document a rationale for continuing the current dose, and staff stated the physician needed to provide that rationale.
A resident with ESRD and dentures had a dental exam that found a chipped tooth, broken teeth, and a need for multiple extractions, but an oral surgeon referral was not completed in a timely manner. The resident reported ongoing mouth discomfort and pain, and staff gave conflicting accounts about who was responsible for the referral and follow-up. The BOM, SSD, ADON, and DON each stated they were unaware the referral had not been completed, and no oral surgeon appointment had been set up.
A resident with Alzheimer's and mobility issues was transferred by a CNA without the required assistance or a gait belt, contrary to the care plan. The CNA acted alone due to the resident's agitation and lack of immediate help, resulting in the resident falling onto the bed. Interviews confirmed the CNA was aware of the proper procedures but did not follow them.
The facility failed to honor the bathing preferences of three residents, leading to a deficiency in treating them with dignity and self-determination. A resident with a stage IV pressure ulcer preferred whirlpool baths but often received bed baths, feeling unclean and uncomfortable. Another resident preferred daily showers but only received one bath per week, while a third resident felt embarrassed due to infrequent bathing. Staff interviews revealed inconsistencies in the facility's bathing schedule and a lack of awareness of residents' preferences, contributing to the deficiency.
Failure to Report Resident-to-Resident Altercation as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident altercation as suspected abuse in accordance with its abuse, neglect, exploitation, and misappropriation reporting policy. The facility’s policy, dated September 2022, required that all reports of resident abuse be immediately reported to the administrator and other officials, including the state survey agency, ombudsman, resident representative, law enforcement, attending physician, and medical director, within specified timeframes (within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations). The policy also required that notices include the residents’ names, room numbers, type of alleged abuse, date and time of the incident, persons involved, and immediate actions taken. Resident #3, who had a diagnosis of unspecified dementia with agitation and severely impaired cognition per a quarterly MDS, was documented in a Health Status Note on 2/20/26 at 9:10 P.M. by LPN C as having aggressive behaviors that day, including hitting another resident, attempting to lock themself in another resident’s room while family was present, and attacking staff (punching, spitting, and attempting to bite). Resident #14, who had a diagnosis of early-onset Alzheimer’s disease and moderately impaired cognition per a quarterly MDS, was later identified as the other resident involved in the altercation. The note indicated that LPN C notified Resident #3’s son and physician after the altercation, but there was no documentation of notification to the administrator or DON, and no report was made to the state agency as required by policy. Interviews revealed confusion and inconsistency regarding reporting responsibilities and whether the incident constituted abuse. A CNA stated that any resident-to-resident altercation, verbal or physical, needed to be reported immediately to the nurse and/or DON. Another LPN stated that all resident-to-resident altercations needed to be reported immediately to the administrator or DON and that the facility had two hours to report abuse allegations to the Department of Health and Senior Services, but believed LPN C had likely informed leadership despite the lack of documentation. The administrator and DON stated they had not been informed of the altercation and therefore did not report it. In a phone interview, LPN C recalled the incident after reviewing the note, stated that Resident #3 had been involved in prior altercations, and acknowledged sending a text to the DON indicating that the two residents had hit each other again and were “just grumpy old ladies” with no injuries. LPN C expressed uncertainty about whether the altercation counted as abuse, believing abuse required malintent and injury, and acknowledged the text might not have clearly conveyed that one resident had hit the other. As a result, the incident was not treated or reported as suspected abuse in accordance with facility policy and regulatory requirements.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to conduct an investigation after a resident-to-resident altercation. Facility policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, required that all allegations be thoroughly investigated, with the Administrator initiating or assigning the investigation to a trained individual. The policy specified that the investigation must include review of documentation and evidence, review of the resident’s medical record and cognitive/physical status, observation of the alleged victim, interviews with the reporter, the resident or representative, physician as needed, staff on all shifts, roommates, family, and visitors, review of events leading up to the incident, and complete documentation of the investigation. Despite this, a Health Status Note dated 2/20/26 at 9:10 p.m. by an LPN documented that a resident with severely impaired cognition and dementia with agitation had aggressive behaviors that day, hit another resident, attempted to lock themself in another resident’s room while family was present, and attacked staff by punching, spitting, and attempting to bite. The resident who was hit had a diagnosis of early-onset Alzheimer’s disease with moderately impaired cognition. The LPN documented that the aggressive resident’s son and physician were notified after the altercation. Staff interviews confirmed that when an allegation of abuse is reported, an investigation is required and that the Administrator is responsible for completing abuse investigations, although one LPN was unsure of the required timeframe. During interviews, the DON and Administrator stated they had not been informed of the resident-to-resident altercation on 2/20/26, did not complete an investigation related to that incident, and acknowledged that an investigation should have been completed. No evidence was presented that any of the investigative steps outlined in the facility’s policy were carried out for this altercation.
Failure to Implement INR Monitoring Orders for Resident on Warfarin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that INR testing was ordered and completed for a resident receiving warfarin therapy, as required by professional standards and the facility’s own anticoagulation policy. The resident was admitted with diagnoses including cognitive symptoms following a nontraumatic subarachnoid hemorrhage and the presence of a prosthetic heart valve, and had an active order for warfarin 5 mg by mouth in the evening. The resident’s care plan identified anticoagulant therapy with an intervention for labs and diagnostics as ordered, and the hospital discharge summary documented that the resident had a high INR upon hospital admission and required an INR check early the following week after admission to the facility, with weekly INR checks for several weeks. Review of the resident’s order summary showed no INR test orders in place, and the DON confirmed that no INR testing had been completed while the resident was at the facility. Interviews with facility staff revealed that the ADON was responsible for entering all admission orders, including lab orders, into the EMR and the lab ordering system, but the ADON no longer worked at the facility. The DON stated there was no process for anyone to verify that all admission orders were correctly entered after the ADON, and was unsure why all of the resident’s admission orders were not in the EMR. The unit manager reported not having seen the resident’s discharge paperwork but stated that, based on the instructions, he or she would have entered INR testing orders and contacted the physician to confirm. RN A stated that he or she was not responsible for entering admission orders. The attending physician reported expecting the facility to follow all discharge instructions, including placing INR orders into the EMR, and stated that the resident should have had weekly INR orders in place given the resident’s history and hospital course. The facility’s anticoagulation policy required identification of anticoagulated residents, review of recent labs and therapeutic monitoring, and close INR monitoring for residents on warfarin, but this process was not carried out for this resident.
Failure to Maintain Accurate Behavioral Monitoring and Updated Care Plan for Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate behavioral monitoring and care planning for a resident with dementia and generalized anxiety disorder who exhibited frequent and escalating aggressive behaviors. The resident was admitted with unspecified dementia with agitation and later diagnosed with generalized anxiety disorder. Multiple Health Status Notes documented episodes of aggression, including yelling at and pushing other residents, hitting and punching staff, kicking, spitting, attempting to bite, and using racial slurs. On several occasions, the resident was described as combative for extended periods, unable to be redirected, refusing meals, and requiring 1:1 observation to prevent confrontations with other residents. Staff notes also described the resident attempting to lock themselves in another resident’s room, attacking a nurse and CNA, and hitting another resident with a plastic hanger. Despite these documented behaviors, the resident’s care plan for mood and behavior had not been updated since 2024, even though the resident’s behaviors had increased in frequency and severity in the months leading up to the survey. The care plan listed general interventions such as administering medications as ordered, monitoring for side effects, approaching the resident calmly, assessing for toileting, hunger, thirst, and pain, and calling the resident by name, and noted that the resident was usually redirectable. These interventions and goals were not revised to reflect the more recent pattern of increased aggression, difficulty with redirection, and the need for 1:1 observation. The MDS Coordinator confirmed that no other staff were involved in care plans, that the care plan could have been more specific, and that the resident’s care plan was not up to date and did not reflect the resident’s current status. The facility also failed to implement and document consistent behavioral monitoring in accordance with its own policy and the physician’s orders. An order for behavioral monitoring, including specific behaviors such as hitting, kicking, spitting, cussing, racial slurs, aggression, and refusing care, was not put in place until late March, despite months of documented aggressive incidents. After the order was initiated, the MAR/TAR for March and April showed no behaviors on multiple days, even though progress notes and staff interviews described frequent aggression and restlessness. Nursing staff, including an LPN, admitted they were not good at charting behaviors, often marked “N” for no behaviors regardless of what occurred, and stated that nurse management did not act on the information when behaviors were documented. The DON and Administrator acknowledged that the resident’s care plan was not current, that behavioral monitoring had not been ordered prior to late March, and that the April MAR/TAR was not accurate, including a failure to mark behaviors on the day the resident pulled a gate off its hinges and struck a nurse in the face, causing a bloody lip. Interviews with CNAs and nurses further demonstrated gaps in behavioral health care and monitoring. CNAs reported that the resident was aggressive more than once a week, with increased behaviors and more physical contact in the last two months, and that the resident’s behaviors were a day-to-day issue. Several CNAs and an LPN stated they did not have access to care plans or that care plans were not up to date or accurate. One NA reported not being educated on how to manage behaviors and primarily using the strategy of leaving the resident alone when aggressive. An LPN and other staff expressed that staff on the special care unit were not adequately prepared or educated to work with residents with significant behavioral symptoms. Collectively, these observations show that the facility did not maintain accurate behavioral monitoring documentation, did not update the care plan to reflect the resident’s escalating behaviors and effective interventions, and did not ensure staff were adequately informed and trained to implement individualized behavioral interventions as required by the facility’s own behavioral assessment and monitoring policy.
Failure to Complete Required Quarterly EDL Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to conduct quarterly Criminal Background Checks, identified in the report as Employee Disqualifications List (EDL) checks, for 8 of 10 sampled employees: AA, BB, CC, DD, EE, FF, GG, and HH. The facility policy dated 8/23/24 stated that the EDL is checked prior to date of hire and quarterly thereafter. Personnel record review showed each of the eight employees had an initial EDL check completed around the time of hire, but the required quarterly checks due in subsequent months were not completed. The missed quarterly checks included multiple overdue periods for several employees, such as checks due in April, May, June, July, November, February, and March that were not completed. During interview, the HR/Business Office Manager stated there were no employee records of quarterly EDL checks and that the facility only performed EDL checks at the time of hire. The Administrator stated EDL checks were supposed to be completed upon hire and quarterly, that the BOM was responsible for completing them, and that no one had been monitoring to ensure the quarterly checks were completed.
Delayed urine specimen pickup and UTI treatment
Penalty
Summary
The facility failed to ensure a resident’s urine specimen was picked up by the laboratory according to acceptable standards of practice and failed to ensure effective coordination with the lab, which delayed treatment for a urinary tract infection. The resident was cognitively intact, frequently incontinent of urine, and had a history of UTI. On 7/17/25, the resident complained of burning with urination, and a UA with culture and sensitivity was ordered. Nursing documentation and staff interviews showed the specimen was collected and placed in the refrigerator, but it was not picked up as expected and remained in the refrigerator days later when the resident asked about results. The resident continued to report dysuria, and the physician and NP noted concern that the UA collected on 7/17/25 still had no results by 7/22/25. Nursing notes showed follow-up with the lab on 7/24/25 because the specimen collected on 7/23/25 could not be located, and staff were told the lab order was not found. The DON was notified, and another urine sample was obtained. Staff interviews indicated the facility expected the courier to pick up specimens on weekdays only, with no weekend pickup, and nurses described repeated difficulty getting the specimen transported and processed in a timely manner. The resident did not start antibiotic therapy until 7/26/25, after multiple urine samples had been collected because of the missing or delayed lab handling. The final urine culture report showed Proteus mirabilis over 100,000 CFU/ml from the specimen collected on 7/23/25. The resident stated treatment was delayed because nobody knew what happened with the first two urine samples and reported feeling much better after starting the antibiotic. Staff interviews confirmed the delay from the first collection to treatment and identified that the specimen should have been picked up much sooner.
Failure to Ensure Timely Vision Services
Penalty
Summary
The facility failed to ensure one resident received timely vision services. The resident was admitted with ESRD and was cognitively intact, used corrective lenses, and reported poor vision without glasses. The resident’s quarterly MDS noted corrective lens use, but the care plan dated 7/3/25 contained no care plan related to vision needs. During interview, the resident stated he/she was missing his/her glasses, had not seen an eye doctor recently, and was using reading glasses because they were better than having no glasses at all. Observation of the resident’s room showed only a pair of reading glasses at the bedside. Record review showed the resident was supposed to be seen by an eye doctor during a facility visit, but the resident was out of the facility at the time and the date aligned with dialysis. The BOM stated the resident was most likely at dialysis when the eye doctor came to the facility and that no appointment was scheduled afterward when the resident missed the visit. The BOM also stated the eye doctor came quarterly, the facility did not choose the dates, and he/she was unaware the resident was missing glasses. The SSD, CNA, LPN, ADON, and DON each stated they were unaware the resident had missed the eye doctor visit or was missing glasses, and several staff identified the SSD or BOM as responsible for arranging vision services. Facility staff gave differing accounts of how missed eye appointments were handled. The ADON stated that if a resident was out of the facility when the eye doctor came, the resident would be seen the next time the eye doctor came, while also stating an outside appointment could be set up if the resident was at dialysis. The DON stated missing glasses would count as emergent if the resident depended on them to see, but was unsure what would need to be done if the resident could not see the eye doctor on the day of the visit. The facility policy stated it was the facility’s responsibility to assist residents and representatives in locating resources, scheduling appointments, and arranging transportation to obtain needed vision services, including replacing lost or damaged devices.
Inadequate Care for Resident With G-Tube
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a G-tube. The resident was admitted with diagnoses including cerebral infarction due to thrombosis of the right middle cerebral artery, dysphagia following the stroke, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, and gastrostomy status. The quarterly MDS dated 6/5/25 showed severely impaired cognition, full dependence on staff for rolling side to side, and the presence of a feeding tube. The care plan identified the feeding tube due to dysphagia and included interventions to administer tube feeding as ordered, keep the HOB elevated 30 to 45 degrees, and clean and change equipment per facility policy. The resident's POS for July 2025 included an order to change the tube feeding bag daily and label it with the date and nurse's initials, elevate the HOB 30 degrees or more at all times as tolerated, and run Isosource 1.5 Cal at 50 ml/hour for 22 hours daily. The MAR/TAR did not show an order for HOB elevation related to tube feeding and did not show an order for daily tube feeding bag changes prior to 7/29/25. During observation on 7/28/25, the resident's HOB was not at a 30-to-45-degree angle and the tube feeding bag was not labeled with the resident's name, date, hang time, rate, or nurse's initials. During later observations, the resident's HOB was at a 30-to-45-degree angle but the resident had slid down in bed and was lying at less than a 30-degree angle, and the tube feeding bag still was not labeled with the hang time or nurse's initials. Another observation showed the HOB was not at a 30-to-45-degree angle. Staff interviews reflected differing expectations about the required HOB angle and labeling of tube feeding bags, and the DON, ADON, and LPN all stated the resident was fully dependent on staff for positioning and that the care plan needed to be updated to reflect current tube feeding orders.
Failure to identify PTSD triggers and provide trauma-informed supportive care
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two residents with PTSD and related mental health diagnoses. For one resident, the record showed a diagnosis of PTSD, a history of abuse, and a trauma-informed care assessment noting past trauma, nightmares, avoidance of reminders, and feeling numb or detached. The care plan listed PTSD and a history of abuse, but the triggers and interventions were not addressed. During interview, the resident stated staff had not asked about triggers or interventions, and staff interviews showed CNA and LPN staff were unfamiliar with the resident’s triggers and expected them to be in the care plan. The MDS Coordinator and DON both stated that PTSD triggers and interventions should have been listed in the care plan. For the second resident, the record showed diagnoses including PTSD, anxiety disorder, major depression, and bipolar disorder, along with a trauma-informed care assessment documenting frightening traumatic experiences, nightmares, avoidance, and being constantly on guard or easily startled. The resident’s care plans addressed trauma, mood, psychological well-being, and PTSD, but did not identify how staff would know when trauma was triggered, what the triggers were, or what staff should do to lessen the likelihood of triggering the resident. The PTSD care plan also did not include a crisis intervention plan despite PASRR recommendations for one due to a history of suicidal ideation and attempts. The record also did not show counseling services were received or offered, and no further PTSD or trauma-informed care assessments were available in the medical record. Interviews with the resident, family member, and staff showed the resident had a long history of physical and sexual abuse, grief over a spouse’s death, and ongoing emotional distress. The resident reported that staff entering the room quickly, certain television shows, and going outside or to medical appointments could trigger PTSD and anxiety. The resident said no one at the facility had asked about PTSD or counseling, though the resident was open to counseling if it was with the right counselor. CNA staff stated they did not know the resident’s PTSD triggers or what staff should do to lessen the likelihood of triggering trauma, and the SSD and DON stated the care plan should identify triggers and how staff could mitigate them. Family also reported the resident had expressed thoughts of harming himself/herself and had requested that male staff not provide personal care, but those preferences and crisis-related concerns were not reflected in the care plan.
Failure to Ensure Nursing Assistants Completed CNA Training Within Required Timeframe
Penalty
Summary
The facility failed to ensure two sampled Nursing Assistants, NA B and NA C, had completed the state-approved CNA training program within four months of facility employment. The facility’s Nursing Assistant Qualifications and Training Requirements policy stated that the facility would not employ any individual as a Nursing Assistant for more than four months unless that individual had completed a training program and competency evaluation approved by the state. Review of NA B’s personnel file showed a hire date of 2/17/25 and that he/she had worked at the facility for over five months, with no record of completed CNA training. Review of NA C’s personnel file showed a hire date of 8/19/24 and that he/she had worked at the facility for over eleven months, also with no record of completed CNA training. During interview, the HR/BOM stated there was no paperwork showing NA B and NA C were CNAs and that both were still working at the facility as NAs. The DON stated NAs could only work in the facility for four months and must become CNAs within 16 weeks of hire, and the Administrator stated he/she tracked NAs to ensure they became CNAs within four months but was not aware NA B and NA C had not done so.
Failure to Document Rationale for Psychotropic GDR Recommendations
Penalty
Summary
The facility failed to ensure appropriate follow-up was completed for pharmacy-recommended gradual dose reductions (GDRs) for two sampled residents, Resident #2 and Resident #6, out of 18 sampled residents. The cited policy stated that residents receiving psychotropic medications should receive GDRs unless clinically contraindicated, and that the physician should document the clinical rationale when tapering was not completed. The deficiency involved the facility’s handling of monthly medication regimen reviews and the lack of documented rationale when the provider disagreed with the pharmacist’s GDR recommendations. For Resident #2, the physician order sheet showed multiple psychotropic medications, including mirtazapine, paroxetine, bupropion, risperidone, and lorazepam for diagnoses including major depressive disorder, anxiety disorder, and restlessness/agitation. The pharmacist’s medication regimen reviews in March 2025 and May 2025 both recommended GDRs for the resident’s medications, but the provider marked disagreement and did not provide a rationale for continuing the current dosages. The record showed the same pattern on both reviews. For Resident #6, the physician order sheet showed brexpiprazole (Rexulti) 2 mg daily for dementia with agitation. The pharmacist’s medication regimen review in May 2025 recommended a GDR, but the provider again marked disagreement without documenting a rationale for continuing the current dose. During interviews, an LPN, the ADON, and the DON each stated that the doctor needed to provide the rationale for not completing the GDRs for Residents #2 and #6, and the DON stated he/she was responsible for ensuring appropriate follow-up was completed for the monthly medication reviews.
Delayed Oral Surgeon Referral After Dental Findings
Penalty
Summary
The facility failed to ensure that one resident was referred to an oral surgeon in a timely manner after a dental exam identified chipped and broken teeth and the need for multiple extractions. The resident was admitted with ESRD, had upper and lower dentures, and had a care plan goal to be free of oral pain and lesions, with an intervention to receive dental consults as needed. A dental summary report noted the resident had a chipped tooth, the dentist could only complete a limited exam because of dental pain, and the resident needed referral to an oral surgeon for multiple teeth removal in four to six areas of the mouth. The resident reported that the broken teeth on the right side of the mouth had been a problem for about a month before the dental exam and believed a referral to an oral surgeon was already in place. During later interviews, the resident said no oral surgeon appointment had been set up, the mouth felt very uncomfortable, and the pain was usually a five out of ten. Observation showed missing teeth. The quarterly MDS did not complete the oral/dental status section. Facility staff gave inconsistent accounts of who was responsible for the referral and follow-up. The SSD said the BOM set up dental services and that no transportation sheets had been received for an oral surgeon visit. The BOM said the SSD was responsible for sending the referral and was unaware the resident needed an oral surgeon. The ADON and DON said the BOM and SSD reviewed dental notes, but both were unaware the referral had not been completed. Staff also stated the referral should have been completed within a week or within 72 hours of receiving the dental note, yet no oral surgeon referral had been completed by the time of the interviews.
Failure to Follow Transfer Protocols for Resident with Alzheimer's
Penalty
Summary
The facility staff failed to adhere to the established policy and the resident's care plan by transferring a resident without the required assistance and equipment. The resident, who had Alzheimer's disease, muscle weakness, abnormal gait, and a history of repeated falls, required assistance with activities of daily living, including transfers. The care plan specified that one to two staff members should assist with transfers and that a gait belt should be used. On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a wheelchair to a bed without using a gait belt or obtaining assistance from another staff member. The resident was agitated, flailing arms, and yelling, which led the CNA to act quickly to calm the resident by placing them in bed. Despite knowing the resident's transfer requirements, the CNA proceeded alone, resulting in the resident falling onto the bed. Interviews with the CNA, a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the facility Administrator revealed that the CNA was aware of the need for assistance and a gait belt but chose to proceed due to the resident's agitation and lack of immediate help. The CNA admitted to not having a gait belt and not waiting for assistance, while the LPN and DON confirmed that the CNA should have followed the care plan and physician's orders.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of three residents, leading to a deficiency in treating them with dignity and self-determination. Resident #1, who was cognitively intact and had a stage IV pressure ulcer, preferred whirlpool baths but often received bed baths due to wound care needs. The resident expressed dissatisfaction with the frequency and quality of baths, feeling unclean and uncomfortable, and had specific preferences regarding staff and timing, which were not consistently respected. Interviews revealed that staff were unaware of the resident's preferences, and the Director of Nursing (DON) was not informed of any complaints. Resident #3, also cognitively intact, preferred more frequent bathing than the once-a-week schedule provided by the facility. The resident expressed a desire for daily showers, as was their routine before entering the facility. Similarly, Resident #4, who required assistance with activities of daily living, preferred more frequent baths, especially during warmer months, but only received one bath per week. This resident felt embarrassed and believed the facility was understaffed, affecting the ability to meet bathing preferences. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the facility's bathing schedule and a lack of awareness of residents' preferences. The facility policy stated residents should receive two baths per week, but staffing issues often led to only one bath per week. The Administrator acknowledged the facility's policy of once-a-week baths and the challenges in accommodating additional requests. Despite the facility's policy and residents' expressed preferences, the care plans did not adequately reflect or ensure adherence to these preferences, contributing to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Concordia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meyer Care Center | 10.8 mi | ★★★★★ | 1 | 0 |
| Apple Ridge Care Center | 15.7 mi | ★★★★★ | 5 | 0 |
| Country Club Rehab And Healthcare Center | 17.2 mi | ★★★★★ | 0 | 0 |
| Warrensburg Manor Care Center | 17.3 mi | ★★★★★ | 0 | 0 |
| Johnson County Care Center | 17.9 mi | ★★★★★ | 17 | 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.