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 Lutheran Home during CMS and state inspections, most recent first.
The facility failed to provide proper portions of protein, vegetables, and carbohydrates to residents, affecting all 46 residents receiving meals from the kitchen. The new menu system lacked portion size guidance, leading to incorrect servings of chicken Philly sandwiches and cucumber salad. Additionally, six residents on a pureed diet did not receive appropriate carbohydrate portions due to the absence of a recipe for pureed chicken Philly sandwiches.
The facility failed to accurately complete MDS assessments for three residents regarding oxygen therapy and discharge documentation. A resident with COPD had incorrect MDS coding for oxygen therapy, while another resident's MDS assessment did not reflect their oxygen use. Additionally, a resident's discharge was inaccurately documented, and an unnecessary MDS assessment was submitted.
A facility failed to include a resident's need for continuous oxygen therapy in the baseline care plan. The resident, who had impaired cognition, required oxygen at six liters per minute via nasal cannula every shift, as per a physician's order. However, this need was not documented in the baseline care plan, which was confirmed by the DON. The facility's policy indicated that the baseline care plan should be a temporary working plan until the comprehensive care plan is completed.
The facility failed to administer oxygen as ordered for two residents. One resident with COPD had an empty oxygen tank on two occasions, despite needing two to four LPM via NC. Another resident, with impaired cognition, was found without the NC in place, despite an order for six LPM. Staff confirmed the deficiencies, and the facility's policy on oxygen administration was not followed.
A resident with dementia experienced a change in condition that was not documented in the facility's medical records. The resident was admitted to the hospital with multiple diagnoses, but the facility failed to record the change in condition, physician notification, or the order to send the resident to the hospital. The Director of Nursing confirmed the absence of necessary documentation, which is against the facility's policy.
The facility did not offer COVID-19 vaccinations to three residents as per CDC recommendations. A resident with COPD and schizophrenia, another with diabetes, and a third with dementia were not offered the vaccine since their last doses in 2021 and 2022. The facility's policy required offering vaccines to new and current residents, but this was not adhered to.
The facility did not conduct an annual performance review for one of its STNAs, as revealed by a personnel file review and confirmed by HR. The STNA, hired in May, had no documented performance review, affecting the oversight of care for all residents.
The facility failed to notify a resident's family of a change in condition and transfer to a hospital for stroke symptoms. The resident, who was cognitively intact and had a diagnosis of cerebral infarct, exhibited stroke symptoms and was transported to the hospital. The facility did not follow its policy to notify the resident's emergency contact, as confirmed by interviews with the family and the DON.
Deficiency in Meal Portion Sizes and Preparation
Penalty
Summary
The facility failed to ensure that residents received proper portions of protein and vegetables, affecting all 46 residents who received food from the kitchen. Specifically, the facility did not provide appropriate portion sizes for chicken and vegetables in the chicken Philly sandwiches, as the new menu system did not include portion sizes. The Dietary Manager (DM) was unable to verify the correct portions due to the absence of guidance from the new menu provider. Additionally, the cucumber salad was served in smaller portions than required, and there was no guidance for portion sizes or preparation methods for mechanical soft or pureed items. For residents on a pureed diet, the facility failed to provide proper portions of carbohydrates, affecting six residents. The pureed chicken Philly sandwich was prepared with an unmeasured amount of chicken, vegetables, and bread, which did not meet the expected portion size. The DM confirmed that there was no recipe for the pureed chicken Philly sandwich, leading to uncertainty about the appropriate portions of protein and carbohydrates for these residents. The preparation method used by the staff did not ensure that each resident received the expected portion of one roll per person.
Inaccurate MDS Assessments for Oxygen Use and Discharge
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents, specifically regarding oxygen therapy and discharge documentation. Resident #18, diagnosed with chronic obstructive pulmonary disease (COPD), had physician orders for oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) from 05/30/24 to 08/05/24. However, the comprehensive MDS admission assessment did not reflect the oxygen therapy, which was confirmed as an error by the MDS Coordinator. Similarly, Resident #199, who was admitted, discharged to the hospital, and then returned, had physician orders for oxygen therapy from 08/16/24 to 08/29/24. The MDS assessment dated 08/23/24 failed to indicate the oxygen therapy, which was also confirmed as an error. Additionally, Resident #15 was discharged to the hospital, but the discharge MDS assessment inaccurately documented the discharge date, and an unnecessary five-day MDS assessment was submitted. These inaccuracies were confirmed by the MDS Coordinator.
Baseline Care Plan Omission for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a baseline care plan included a resident's need for continuous oxygen therapy. This deficiency was identified during a review of the medical record for a resident who was admitted, discharged to the hospital, and then returned to the facility. The comprehensive Minimum Data Set (MDS) assessment indicated that the resident had impaired cognition. A physician's order specified that the resident required oxygen at six liters per minute via nasal cannula every shift. However, the baseline care plan did not reflect this critical need for oxygen. The Director of Nursing confirmed that the baseline care plan was incomplete in this regard. The facility's policy stated that the baseline care plan should serve as a temporary working care plan until the comprehensive care plan is completed.
Failure to Administer Oxygen Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen was administered per physician order for two residents. Resident #18, diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order for oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. However, observations on two separate occasions revealed that Resident #18's oxygen tank was empty while the NC was applied, indicating a failure to provide the prescribed oxygen therapy. Licensed Practical Nurses (LPNs) confirmed the tanks were empty, and it was noted that Resident #18 used approximately five tanks of oxygen daily. Resident #199, who had impaired cognition, was also affected by the facility's failure to administer oxygen as ordered. After being discharged to the hospital and returning to the facility, Resident #199 had a physician order for oxygen at six LPM via NC every shift. However, a family member observed the NC was not in place while Resident #199 was sitting in his recliner, and further observations confirmed the NC was under him while he was lying in bed. Interviews with staff revealed that care had not yet been provided to Resident #199, despite the shift having started. The facility's policy on oxygen administration, which requires oxygen to be provided at the prescribed amount, was not followed in these instances.
Failure to Document Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the medical record accurately reflected a change in condition for a resident, which is a deficiency in maintaining medical records according to accepted professional standards. The resident, who had been readmitted with a diagnosis including dementia, experienced a change in condition that was not documented in the medical records. Specifically, on the date of the incident, there was no documentation of the resident's change in condition, the physician being notified, or the physician's order to send the resident to the emergency room. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged the absence of necessary details in the electronic medical record. The resident was admitted to the hospital with several diagnoses, including altered level of consciousness, hypoglycemia, urinary tract infection, congestive heart failure, and medication effect. Despite the hospital admission, the facility's records did not reflect the change in condition or the steps taken to address it, such as notifying the physician or the resident's representative. The facility's policy on Notification of Resident's Condition, which requires completed notifications to be documented in the medical record, was not followed in this instance.
Failure to Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to residents in accordance with CDC recommendations, affecting three residents out of nine reviewed. Resident #18, who has chronic obstructive pulmonary disease and schizophrenia, was admitted with impaired cognition and had not been offered a COVID-19 vaccine since their last vaccination in October 2022. The Infection Preventionist confirmed that new admissions were not routinely offered the vaccine or provided with education about it. Similarly, Resident #29, who is cognitively intact and has type two diabetes mellitus with diabetic neuropathy, had not been offered a COVID-19 vaccine since their last vaccination in December 2021. Resident #45, who has dementia and is severely cognitively impaired, also had not been offered the vaccine since their last vaccination in December 2021. The facility's policy, reviewed in August 2023, stated that vaccines should be offered to new and current residents unless contraindicated, but this was not followed. The CDC guidance recommends vaccination for people at high risk, including those in long-term care facilities.
Failure to Conduct Annual Performance Review for STNA
Penalty
Summary
The facility failed to ensure that one of four State tested Nursing Assistants (STNA) received an annual performance review. This deficiency was identified during a personnel file review and staff interview. The personnel file of the STNA, who was hired on 05/19/23, lacked documentation of a completed yearly performance review. This oversight was confirmed during an interview with a Human Resources representative, who verified that no performance review had been conducted for the STNA in question.
Failure to Notify Family of Resident's Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify the family of a resident's change of condition and transfer to a local hospital for evaluation and treatment of stroke symptoms. This deficiency affected one resident who was cognitively intact and had a diagnosis of cerebral infarct. The resident identified his brother as his emergency contact upon admission. On the day of the incident, the resident exhibited right-sided facial droop, numbness, and tingling, prompting the nurse to call the on-call physician and subsequently 911 for emergency medical services. The resident was transported to the nearest hospital for evaluation and treatment. However, the nursing progress notes revealed no documentation of family notification following the resident's discharge from the facility. Interviews with the resident's family member and the Director of Nursing confirmed that the family was not informed of the change in condition or the hospital transfer. The facility's policy on notification of residents' condition, which mandates notifying the POA or representative in case of significant changes, was not followed. This deficiency was investigated under Complaint Number OH00152599.
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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 Napoleon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northcrest Rehab And Nursing Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Vancrest Health Care Ctr Of Ho | 8.6 mi | ★★★★★ | 6 | 0 |
| Fulton Manor Nursing & Rehab C | 11.2 mi | ★★★★★ | 13 | 0 |
| Ayden Healthcare Of Wauseon | 11.5 mi | ★★★★★ | 5 | 0 |
| Grand Rapids Care Center | 13.3 mi | ★★★★★ | 2 | 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.