Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Food was stored unsafely and without proper dating or labeling in multiple kitchen and resident food storage areas, including spoiled produce, expired items, and opened containers left undated or unlabeled. The high-temp dishwasher did not reach the required wash and rinse temperatures, and a dietary employee was observed touching food and serving items with contaminated gloves after handling non-food surfaces.
The facility failed to ensure kitchen trash cans were covered. Surveyors observed three 30-gallon trash cans without lids in the kitchen, including cans near the pot storage, stove, and handwashing station, each partially filled with garbage. An LDM confirmed the cans lacked lids and should be covered, and the Administrator stated there was no policy addressing covered trash cans. The issue affected all residents except one resident who received no food by mouth.
Failure to notify physician of missed lorazepam doses: A resident with dementia, severe cognitive impairment, and anxiety disorder did not receive scheduled lorazepam doses because of excessive sedation, but the DON confirmed there was no evidence the physician was notified. The MAR showed multiple missed doses, and the chart lacked documentation of physician notification as required by facility policy.
A resident with dementia, anxiety disorder, and severe cognitive impairment received scheduled lorazepam 1 mg TID and was repeatedly observed asleep or difficult to arouse in her wheelchair, dining area, and common areas. The DON confirmed the medication was being used to prevent her from getting out of her wheelchair, and the care plan did not include non-pharmacological redirection measures for anxiety.
Failure to Monitor Edema and Apply Ordered Compression Wraps: A resident with CHF, lymphedema, and edema had a care plan and orders for weight monitoring and daytime compression wraps, but weights were not monitored as expected and edema monitoring was inconsistently documented. Staff interviews confirmed the resident’s bilateral lower-extremity edema was not being monitored daily, and an observation found the compression wraps on the floor instead of on the resident’s legs as ordered; the resident and CNA both confirmed the wraps were not applied.
Failure to maintain dialysis treatment communication with the dialysis center occurred for a resident receiving scheduled dialysis. The resident had ESRD along with osteomyelitis, a chronic foot ulcer, PVD, Afib, and DM2, and was cognitively intact. Only two dialysis communication forms were found, and an LPN and the DON confirmed the facility did not maintain the required pre- and post-dialysis communication.
Failure to Perform Hand Hygiene During Wound Care: An RN failed to perform hand hygiene after removing gloves and before putting on new gloves while completing wound care for a resident with a diabetic foot ulcer, osteomyelitis, ESRD, PVD, Afib, and DM2. During NPWT dressing care, the nurse removed soiled dressings, handled equipment, and continued the procedure without hand hygiene between glove changes; the RN and UM confirmed the omission.
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.
Food Storage and Serving Sanitation Deficiencies
Penalty
Summary
Food was not stored in a sanitary manner in the kitchen and resident food storage areas. In the dry storage area, a box of sweet potatoes was placed on top of the can storage rack, and one sweet potato had a black fuzzy substance on it while gnats flew out when the box was touched. In the walk-in cooler, a box of individually wrapped cucumbers was mushy, and multiple opened food items were undated or expired, including thickened juices, prune juice, thickened lemon water, an unlabeled container with a red substance, and an opened container of fruit salad past its expiration date. In the refrigerator across from the nurses' station, staff found opened and undated almond milk, coffee creamer, nutritional shakes, prune juice, tea, whipped topping past expiration, and an unlabeled loaf in a bag. In the food storage area across from the 200-hall nurses' station, there was opened and undated peanut butter, chips, and cheese crackers. The Dietary Manager confirmed the findings and stated food items should be dated and labeled, and that expired foods should be disposed of.
Uncovered Kitchen Trash Cans
Penalty
Summary
The facility failed to ensure kitchen trash cans were covered. During observation of the kitchen area, three 30-gallon trash cans were found without lids: one next to the pot storage that was half full of garbage, one next to the stove that was one-quarter full of garbage, and one by the handwashing station that was one-quarter full of garbage. Dietary Manager #21 confirmed that the trash cans did not have lids and stated they should be covered. The Administrator later stated the facility did not have a policy addressing the need for trash cans to be covered. The deficiency affected all residents except one resident identified by the facility as receiving no food by mouth.
Failure to Notify Physician of Missed Lorazepam Doses
Penalty
Summary
The facility failed to notify the physician when Resident #13 did not receive prescribed lorazepam as ordered because of a change in condition. Resident #13 was admitted with diagnoses including dementia, cognitive communication deficit, anxiety disorder, and a history of falling. The quarterly MDS dated 07/01/26 showed a BIMS score of 00, indicating severe cognitive deficit, and the resident required substantial assistance with eating and was dependent on others for all other ADLs. The physician order dated 01/13/26 directed lorazepam 1 mg by mouth three times daily for anxiety disorder and required close observation for significant side effects such as drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior. The MAR showed the medication was not administered on 07/20/26 at 1:00 P.M. and 9:00 P.M. and on 07/21/26 at 5:00 A.M. Nursing progress notes contained no evidence that the physician was notified of these missed doses. The DON confirmed the doses were not given due to excessive sedation and verified there was no evidence the physician was notified. The facility policy stated the physician should be notified when medications were not given, refused, or given at a time other than scheduled, and that the notification should be documented in the resident's chart.
Chemical restraint used to keep a resident from getting out of wheelchair
Penalty
Summary
The facility failed to ensure a resident was free from chemical restraint when Resident #13, who had diagnoses of dementia, cognitive communication deficit, anxiety disorder, and a history of falling, was receiving scheduled lorazepam 1 mg by mouth three times daily for anxiety. The resident’s quarterly MDS showed a BIMS score of 00, indicating severe cognitive deficit, and she required substantial assistance with eating and was dependent on others for all other ADLs. The care plan included monitoring for adverse reactions to anti-anxiety therapy, but it did not include non-pharmacological measures for staff to use to redirect the resident when anxiety occurred. Observations showed Resident #13 repeatedly sitting in her wheelchair with her eyes closed, appearing to sleep, including in the common area, at the dining table, and near the nurses’ station. At times she did not respond to verbal or tactile stimulation, and at other times she briefly opened her eyes when her name was called before returning to a posture with her head down or tilted back and eyes closed. An RN stated it seemed the resident did not have control of her upper body, and the DON confirmed the resident had been sleeping a lot and was receiving scheduled lorazepam because she continually tried to get out of her wheelchair. The DON further stated the reason for using scheduled lorazepam was to prevent the resident from getting out of her wheelchair and that the only non-pharmacological measure attempted was a PT consultation.
Failure to Monitor Edema and Apply Ordered Compression Wraps
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for the management of edema for one resident with chronic obstructive pulmonary disease, lymphedema, and heart failure. The resident’s care plan identified fluid overload related to CHF, edema, and lymphedema, with interventions to monitor and document signs and symptoms of fluid overload, including sudden weight gain, and to apply compression stockings in the morning and remove them at night as tolerated. A physician order also directed monthly weights, and another order directed compression wraps to be applied during the day to both lower extremities. Review of the record showed the resident’s weights were obtained weekly in July and August 2025, monthly from September through December 2025, daily from 01/01/26 through 01/08/26, and then monthly from February through July 2026. Nursing progress notes and assessments documented edema monitoring only on 02/15/26 and 03/22/26. During interview, an LPN confirmed bilateral lower extremity edema and weights were not monitored daily, and the DON stated there was no documentation of edema monitoring and that weights were only monitored monthly despite the resident’s edema and heart failure. On observation, the resident’s compression wraps were found on the floor next to her chair and not applied to her bilateral lower extremities as ordered; the resident stated she had not been asked to have her weight monitored daily and had not refused, and she also stated the wraps had not been applied that day. A CNA confirmed the wraps were not on before the shower and were not applied afterward, and an LPN confirmed the wraps were not on as ordered.
Failure to Maintain Dialysis Treatment Communication
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was deficient because the facility did not maintain pre- and post-dialysis treatment communication with the dialysis center for Resident #6. Resident #6 was admitted with diagnoses including osteomyelitis of the left foot, a non-pressure chronic ulcer of the left heel and midfoot, end stage renal disease, peripheral vascular disease, atrial fibrillation, and Type Two diabetes mellitus. The MDS assessment dated [DATE] indicated the resident was cognitively intact and did not display behaviors or refusals of care. A physician order dated 05/23/26 showed dialysis was scheduled for Mondays, Wednesdays, and Fridays, and the care plan included a dialysis intervention dated 03/27/26. Review of the dialysis treatment communication forms showed only two forms, dated 04/17/26 and 07/17/26, were obtained. An LPN stated on 07/22/26 that she had not seen any dialysis treatment communication forms for Resident #6 and that management was working on obtaining them, and the DON verified the facility did not maintain pre- and post-dialysis treatment communication with the dialysis center and should have been.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene was performed during wound care for Resident #6. Resident #6 was admitted with diagnoses including osteomyelitis of the left foot, a non-pressure chronic ulcer of the left heel and midfoot, end stage renal disease, peripheral vascular disease, atrial fibrillation, and Type Two diabetes mellitus. The MDS assessment indicated he was cognitively intact and did not display behaviors or refusals of care, and he had a diabetic foot ulcer. A physician order dated 07/16/26 directed negative pressure wound therapy to the diabetic wound on his right foot, with instructions to cleanse the wound and peri-wound, soak the wound in hypochlorous acid wound cleanser, apply skin prep and drape, place green foam in the wound bed, set the machine to 125 mmHg, wrap with fluff gauze, and change the dressing every Tuesday and Friday. During observation on 07/21/26 at 2:15 P.M., RN #53 removed the soiled dressing and removed her gloves, but did not perform hand hygiene before putting on new gloves and continuing with the soak step. Later in the same wound care, she obtained the wound vac power supply from the floor, connected the power cord, removed her gloves again, and did not perform hand hygiene before donning new gloves and placing the sponge in the wound bed. RN #53 and the Unit Manager confirmed hand hygiene was not performed between glove changes and should have been during the wound care.
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 | ★★★★★ | 7 | 0 |
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