Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Home during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide complete transfer and bed-hold notices during resident hospitalizations, omitting required contact information for the State Long-Term Care Ombudsman and appeal agencies, and failing to notify the Ombudsman as required. Staff interviews confirmed a lack of awareness and absence of a policy addressing these requirements.
Staff did not follow established recipes or measurement protocols when preparing pureed foods, resulting in unmeasured and inappropriate ingredients being used, such as water instead of broth and omission of margarine. This practice affected multiple residents on pureed diets, as food was not prepared in a manner that conserved nutritional value, flavor, or appearance.
Surveyors found that food stored in a unit refrigerator was not properly labeled or dated, and the refrigerator temperature was consistently above the recommended safe range. Despite facility policy requiring labeling, dating, and daily monitoring of food and refrigerator temperatures, these procedures were not followed, as evidenced by unlabeled food items and temperature logs showing persistent out-of-range readings.
Surveyors found that staff, including nurses, wound care providers, and CNAs, repeatedly failed to wear required PPE such as gowns and gloves during high-contact care activities like wound care, incontinence care, catheter care, and tube feeding for residents with wounds, catheters, and feeding tubes. These actions were observed despite facility policies and care plans mandating Enhanced Barrier Precautions, and in some cases, necessary signage was missing from resident rooms. Staff and leadership interviews confirmed these lapses were not in line with facility expectations.
Two residents did not receive required ADL care, including scheduled showers and nail care, as outlined in their care plans and facility policy. One resident missed multiple showers due to staff absence and lack of communication, while another did not receive timely podiatry services for nail trimming, resulting in unmet care preferences.
Two residents with pressure injuries did not receive comprehensive wound assessments as required by facility policy. One developed a pressure injury in the facility that was not fully assessed at onset, and another was readmitted with a pressure injury that was not comprehensively evaluated for several days. Nursing staff and the DON confirmed the lack of complete assessments, resulting in deficiencies in treatment and care planning.
Surveyors found that insulin and eye drop medications in two medication rooms and one medication cart were either expired or not dated when opened, contrary to facility policy and professional standards. An LPN confirmed that these medications should have been dated and discarded once expired. The facility was notified of these labeling and storage deficiencies.
A resident with chronic kidney disease and dysuria, who was frequently incontinent of bladder, did not have a comprehensive care plan for urinary incontinence. The care plan only included basic toileting assistance and use of a brief, without addressing the reasons for incontinence, type, goals, or additional interventions, and did not reference the resident's renal disease or dysuria. Facility policy required more detailed planning, but this was not present.
Two residents with chronic pain conditions did not receive comprehensive pain management services, as required by professional standards. One resident experienced frequent, severe pain and was not offered non-pharmacological interventions, with no pain care plan or thorough assessment in place. Another resident's care plan lacked specific pain management goals and did not document all prescribed pain medications or complete pain assessments. The DON confirmed the absence of comprehensive pain care plans and assessments for both residents.
Surveyors found that several residents with serious mental illness, as identified by PASRR screenings and medical diagnoses, were not accurately documented in the MDS assessments. Staff acknowledged that the assessments were coded incorrectly, resulting in the omission of serious mental illness status in the required documentation.
A resident sustained a bruise near their eye due to improper use of a Hoyer lift with support bars, which staff were not trained to use. The lift's side bars do not lock in an upward position, and during a transfer, a bar fell and hit the resident. The facility failed to provide training or implement preventive measures following the incident.
The facility failed to ensure food safety and proper storage, affecting all residents. Staff did not test the sanitizing solution correctly or log results, and the unit refrigerator on 2E had unlabeled, undated food and was unclean, with no current temperature log.
The facility failed to ensure food was prepared to conserve nutritive value for 8 residents on a pureed diet. The Cooks Helper did not follow a recipe or the IDDSI framework, using unmeasured amounts of water and thickening agent, and did not use a liquid with nutritious value.
The facility failed to ensure proper catheter care and privacy for three residents, leading to multiple observations of uncovered catheter drainage systems and bags placed directly on the floor. Despite care plans requiring protective measures, the facility did not provide privacy bags or barriers, compromising the residents' dignity and increasing the risk of infection.
A facility failed to provide proper pharmaceutical services when an LPN did not follow safety protocols while administering insulin to a resident with Alzheimer's, Chronic Kidney Disease, and Type 2 Diabetes. The LPN did not recap the needle, waved it in the air, and donned gloves while holding the uncapped needle, leading to safety concerns.
A resident with multiple diagnoses was prescribed an antibiotic for a respiratory infection before obtaining a respiratory panel, which later confirmed a viral infection. Despite the results, the antibiotic treatment continued without documented follow-up with the prescribing physician, highlighting a deficiency in the facility's management of the resident's drug regimen.
The facility failed to maintain a medication error rate below 5%. Errors included administering expired Novolin insulin to one resident and Aspirin with an illegible expiration date to another. The facility's policies on medication disposal and labeling were not followed.
The facility failed to ensure proper storage and labeling of medications, with surveyors finding undated, opened eye drops, unlabeled medications, expired insulin, and improper storage practices. Additionally, a salad was found in the medication fridge, and the refrigerator temperature was above the acceptable range.
Failure to Provide Required Transfer and Bed-Hold Notices with Ombudsman and Appeal Information
Penalty
Summary
Surveyors identified that the facility failed to provide the required documentation and notifications during resident transfers to the hospital. Specifically, transfer and bed-hold notices for multiple residents did not include the email address for the state agency, the facility, or the contact information for the Office of the State Long-Term Care Ombudsman. Additionally, the notices lacked information on how to contact the Ombudsman, and the required notifications were not sent to a representative of the Ombudsman office. This deficiency was observed in the records of four out of five residents reviewed for hospitalizations. Interviews with facility staff, including the Nursing Home Administrator and Social Worker, revealed a lack of awareness regarding the requirement to include Ombudsman contact information and to notify the Ombudsman during transfers, not just discharges. The facility also did not have a specific policy or procedure addressing transfer notice requirements. The documentation reviewed consistently omitted the necessary appeal contact emails and Ombudsman details, and staff confirmed that these notifications were not being completed as required.
Failure to Follow Pureed Food Preparation Protocols
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to established recipes and procedures designed to conserve nutritional value, flavor, and appearance. During observation, a cook prepared pureed greens without accurately measuring the amount of greens, thickener, or liquid added. The cook used a strainer with no visible measurement markings to estimate the quantity of greens and added an unmeasured amount of thickener and water, contrary to the recipe instructions. The recipe specifically directed that margarine be added and that any liquid used for thinning should not be water, but rather a suitable alternative such as broth. However, margarine was omitted, and water was used for thinning, both in unmeasured amounts. The cook reported that he was trained to add water as needed to achieve the desired consistency and did not follow a specific measured amount for either thickener or liquid. The recipe required gradual addition of thickener and liquid, but the cook added both all at once. The Dining Director confirmed that the recipe in use did not specify the amount of thickener and acknowledged that the correct liquid for thinning should be broth or a similar alternative, not water. The strainer used to measure the greens was also found to lack any measurement indicators, making it impossible to confirm the quantity used. These deviations from the recipe and facility policy resulted in pureed food being prepared in a manner that did not ensure consistency, nutritional value, or palatability for residents on a pureed diet. The deficiency had the potential to affect eight residents who required pureed diets, as the food preparation did not adhere to the standards set forth by the facility's policies and the registered dietician's or physician's orders.
Failure to Properly Store and Label Resident Food and Maintain Safe Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of three resident unit refrigerators. Specifically, food items stored in the refrigerator were not labeled with resident names or dates, and some items were not dated at all. The facility's own policy required all perishable food brought in by family or visitors to be labeled with the resident's name, date received/opened, and discard date, and for nursing staff to monitor and document this daily. However, observations revealed unlabeled and undated food items, including Styrofoam containers and a plate with only a resident's name but no date. Additionally, the refrigerator temperature was consistently above the recommended safe range for food storage. The temperature gauge inside the refrigerator was observed at 68 degrees Fahrenheit, and a review of the temperature log from January through June showed all recorded temperatures were above 41 degrees Fahrenheit, with most readings between 48-52 degrees. The facility's policy and posted instructions required refrigerator temperatures to be maintained between 37-41 degrees Fahrenheit. Despite this, the temperature log was regularly initialed as if the refrigerator was within range, and no corrective action was documented in response to the out-of-range temperatures.
Failure to Follow Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
Surveyors observed multiple instances where staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact resident care activities. In several cases, staff—including registered nurses, wound care physicians, nurse managers, wound technicians, certified nursing assistants, and advanced practice nurse practitioners—did not wear required personal protective equipment (PPE) such as gowns and gloves while performing wound care, incontinence care, catheter care, and tube feeding care. These lapses were directly observed during wound treatments for residents with pressure injuries, indwelling catheters, and feeding tubes, despite clear signage and care plans indicating the need for EBP. Specific incidents included a registered nurse performing wound care on a resident with multiple pressure injuries and a Foley catheter without donning a gown, as well as a wound care physician conducting wound debridement with only one glove and using an ungloved hand. Certified nursing assistants were seen providing incontinence and peri care without changing gloves or performing hand hygiene between tasks, and in some cases, did not wear gowns as required. Additionally, a licensed practical nurse was observed flushing a resident's feeding tube without wearing a gown, and there was no EBP sign on the resident's door, contrary to facility policy. Interviews with staff and leadership confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents on EBP, and that signage should be present to alert staff to these requirements. Staff acknowledged lapses as oversights or due to missing signage, and leadership reiterated the policy requirements. The surveyors documented these deficiencies as failures to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases.
Failure to Provide Scheduled Showers and Nail Care per Care Plan
Penalty
Summary
Two residents did not receive necessary assistance with activities of daily living (ADLs) as required by their care plans and facility policy. One resident, with a history of a rare neuromuscular disorder, bladder dysfunction, pain, cellulitis, and urinary retention, was dependent on staff for bathing and had a physician order for weekly showers. On the scheduled shower day, the assigned shower aide was absent due to illness, and the resident was not provided with a shower or an alternative bathing method. The resident was not informed about the missed shower and expressed concern, noting that a shower had also been missed the previous week. Documentation confirmed that the last shower provided was nearly two weeks prior, despite the resident's dependence on staff and stated preference for showers. Another resident, diagnosed with diabetes mellitus with neuropathy and requiring assistance with personal care, did not receive regular nail care as outlined in the care plan and facility policy. The care plan specified referral to podiatry for nail trimming, but the resident's toenails were observed to be long, and the resident expressed a preference for short nails. Staff interviews revealed that the resident was not on the current podiatry list, and there was a lack of communication regarding the need for podiatry services. The facility required consent from the resident's power of attorney for podiatry visits, which had not been obtained in a timely manner, resulting in the resident not receiving necessary nail care. The facility's policy stated that all residents should receive weekly showers or baths and regular nail care as needed. However, both residents did not receive these services according to their care plans and preferences. Staff interviews and documentation review confirmed that the facility failed to provide the required ADL care, and no additional information was provided to explain the lack of services.
Failure to Complete Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. For one resident with dementia, CHF, and diabetes, a pressure injury developed while in the facility. Although staff documented the presence of an open area and initiated wound care, a comprehensive assessment of the wound—including staging, wound bed, peri-wound, and other required characteristics—was not completed at the time of discovery. The care plan included interventions such as pressure-reducing devices and repositioning, but the initial assessment did not meet the facility's policy requirements for a comprehensive evaluation. Another resident, admitted with a history of cancer and at risk for pressure injuries, developed a pressure injury to the sacrum that was appropriately assessed prior to a hospital transfer. Upon readmission, the resident's pressure injury was not comprehensively assessed for three days, and the plan of care did not reflect the presence of an actual pressure injury or include comprehensive interventions. Documentation provided after readmission only included wound measurements and lacked detailed assessment of wound characteristics as required by facility policy. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not completed as required for both residents. The facility's own policy mandates a thorough evaluation of wounds, including size, depth, location, stage, wound base, peri-wound, drainage, pain, and wound edges, but this was not followed. As a result, the facility did not ensure that residents with pressure injuries received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled in accordance with accepted professional principles. Specifically, in two medication rooms and one medication cart, insulin vials and pens, as well as eye drop solutions, were found either expired or not dated when opened. Facility policy requires that multi-dose medications be dated when opened and that expired or contaminated medications be removed and disposed of properly. However, surveyors found multiple instances where insulin and eye drops were open and in use without being dated, and some insulin was found to be expired but still stored in the medication rooms and cart. During the observations, surveyors identified specific medications, such as Lispro insulin, Novolin 70/30 insulin, Lantus insulin pens, Brimonidine eye drops, and Prednisolone eye drops, that were either expired or lacked an opening date. An LPN confirmed that all these medications should have been dated when opened and discarded once expired. The facility was notified of these concerns during the exit meeting, and no additional information was provided.
Lack of Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease and dysuria, who was frequently incontinent of bladder, did not have a comprehensive care plan addressing her urinary incontinence. The resident's Minimum Data Set (MDS) and Care Area Assessment (CAA) indicated frequent incontinence and a need for assistance with toileting, including transfers and hygiene. Despite these documented needs, the care plan only included an intervention to offer toileting every 2-3 hours and as needed, and to use a brief, without specifying the reasons for incontinence, the type of incontinence, specific goals, or additional interventions. There was also no documentation in the care plan regarding the resident's renal disease or dysuria. Review of the CNA care card showed similar limited instructions, and interviews with the Director of Nursing confirmed that no further interventions or comprehensive planning were in place for the resident's bowel and bladder incontinence. The facility's policy required care plans to include goals and considerations of risks affecting the resident's health, but these elements were missing in this case. No additional information was provided by facility leadership to explain the lack of a comprehensive care plan for the resident's urinary incontinence.
Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management services consistent with professional standards of practice for two out of five residents reviewed. For one resident with a history of fibromyalgia and chronic pain, documentation showed frequent and severe pain, with pain scores ranging from 5 to 10 prior to administration of as-needed opioid analgesics. Despite this, there was no comprehensive pain care plan or thorough pain assessment in the resident's records, and the care plan lacked any interventions for pain. The resident reported that pain medication was only effective for a short period and that non-pharmacological interventions were never offered, even though the resident expressed willingness to try them. Medication administration records indicated repeated use of as-needed pain medication, with several instances where pain was not relieved and no follow-up actions were documented. Another resident with diagnoses including unspecified pain, low back pain, and dysuria was also not provided with a comprehensive pain management plan. Although the resident received scheduled pain medications and reported that these were effective, the care plan only referenced pain management under a self-care deficit section and did not include specific problems or goals related to pain. Non-pharmacological interventions were minimally documented, and the care plan failed to mention all prescribed pain medications. Pain assessments were incomplete, lacking details such as pain location, acceptable pain levels, and effectiveness of interventions. Medication administration records did not consistently document pain levels using the required scale. Interviews with the Director of Nursing confirmed the absence of comprehensive pain care plans and assessments for both residents. When asked about the adequacy of the care plans and assessments, the DON did not provide an answer. No additional information or justification for the lack of comprehensive pain management documentation was provided by facility leadership when requested by surveyors.
Inaccurate MDS Documentation for Residents with Serious Mental Illness
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate and complete assessments for residents with serious mental illness, as required by regulatory standards. Multiple residents with diagnoses such as bipolar disorder, schizophrenia, major depression, anxiety, and psychotic disorders had Preadmission Screening and Resident Review (PASRR) Level I and II screenings indicating the presence of serious mental illness. However, these findings were not accurately documented in Section A1500 of the Minimum Data Set (MDS) assessments. In several cases, the MDS assessments incorrectly indicated that the residents did not have a serious mental illness, despite clear evidence from PASRR screenings and medical diagnoses. Interviews with facility staff, including social workers and the Director of Nursing, confirmed that the MDS assessments were coded incorrectly for these residents. Staff acknowledged the errors when questioned by surveyors, and no additional explanations were provided for the inaccuracies. The deficiencies were observed for all reviewed residents with serious mental illness and PASRR screenings, indicating a pattern of inaccurate documentation in the residents' comprehensive assessments.
Inadequate Training on Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure staff were adequately trained to use a specific type of Hoyer lift with support bars, resulting in a resident sustaining a bruise near their eye. The incident occurred when the resident was being transferred using the Hoyer lift, which has side bars that do not lock in an upward position. During the transfer, one of the bars fell and hit the resident on the left side of their face, causing a hematoma. The resident, who is cognitively intact and dependent on staff for transfers, reported that their eye still hurt weeks after the incident. The investigation revealed that the staff involved in the incident were not trained on the specific Hoyer lift before or after the event. The Assistant Director of Nurses and the Unit Manager did not implement any preventive measures or conduct staff training following the incident. The staff development coordinator confirmed that no competencies were in place for this particular lift, which was originally from the Veterans Administration. The facility's policy on safe transfers was not effectively implemented, as evidenced by the lack of staff training and preventive interventions to avoid future occurrences.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility did not ensure food was stored and served in accordance with professional standards for food safety. Staff failed to test the Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. The sanitizing sink was tested through the foam layer on top of the water, which is not the correct procedure. Additionally, the facility did not log or document the testing results, and the sanitizing sink was only tested daily instead of every 4 hours as required. This affected all 136 residents who receive food prepared by the facility kitchen. The unit refrigerator on 2E had multiple food items that were not labeled with the resident's name, and open food was not dated. The refrigerator was unclean, with stains of old food and liquid draining out of a plastic container with pickles. There was no current temperature log posted on the refrigerator, and temperatures had not been documented since December of 2023. This had the potential to affect all 41 residents who can use the resident's unit refrigerator on 2E. Interviews with staff revealed that the night shift was responsible for logging refrigerator temperatures and ensuring cleanliness, but this was not being done. The Nursing Unit Manager acknowledged the lack of a current temperature log and the presence of unlabeled and undated food items. The facility did not have a policy regarding the maintenance of resident unit refrigerators, contributing to the observed deficiencies.
Failure to Follow Recipe and IDDSI Guidelines for Pureed Food Preparation
Penalty
Summary
The facility did not ensure that food was prepared to conserve nutritive value, affecting 8 residents on a pureed diet. The Cooks Helper (CH-H) did not follow a recipe for preparing texture and modified consistency diet for pureed food. Instead, CH-H used an unmeasured amount of water and thickening agent, judging the texture by eye rather than following the IDDSI framework, which includes specific testing methods like the fork test. Additionally, CH-H did not use a liquid with nutritious value, opting for water instead of broth or another nutrient-rich liquid. The recipe binder available had serving sizes for 200 people, which CH-H found impractical for the current needs, leading to the omission of recipe use. During the survey, the Executive Chef (EC-K) and Director of Dining and Hospitality (Director-L) were informed about the issue. EC-K acknowledged that staff should be using the recipes and mentioned that they sometimes use broth for pureeing food. However, on this occasion, water was used. The surveyor noted that the recipe binder would be adjusted to include measurements for smaller serving sizes. The deficiency was communicated to the Chief Executive Officer (CEO-C), Assistant Administrator (AA-I), and Director of Nursing (DON-B).
Failure to Ensure Proper Catheter Care and Privacy
Penalty
Summary
The facility did not ensure that three residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and maintain their dignity. Resident 61 was observed multiple times with their catheter drainage bag system uncovered and laying on the floor, contrary to the care plan that required the drainage system to be stored inside a protective dignity pouch and not touch the floor. Despite multiple observations by the surveyor, the facility did not provide a privacy bag or any barrier between the drainage system and the floor for Resident 61. Resident 66, who had a recent urinary tract infection and required a urinary catheter, was also observed multiple times with their catheter drainage system uncovered and hanging on the bed frame. The surveyor noted blood-tinged urine in the drainage system bag, but no privacy bag or barrier was observed. The care plan for Resident 66 included monitoring for signs and symptoms of infection, but the facility failed to ensure the catheter drainage system was covered for privacy. Resident 63, with multiple diagnoses including Alzheimer's, chronic kidney disease, and a history of urinary tract infections, was observed with their catheter drainage bag uncovered and, at times, directly on the floor. The care plan for Resident 63 included interventions to keep the catheter patent and free of infection, but the facility did not consistently ensure the catheter drainage system was covered or off the floor. The surveyor noted the drainage valve tubing touching the ground, which was not addressed by the facility staff despite multiple observations and interviews with the Director of Nursing and Unit Manager.
Improper Insulin Administration
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of each resident, specifically in the administration of insulin. A Licensed Practical Nurse (LPN) failed to safely administer insulin to a resident with Alzheimer's Disease, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. The LPN did not follow proper procedures for handling and administering the insulin, including not recapping the needle after drawing the insulin, waving the uncapped needle in the air, and walking into the resident's room with the uncapped needle. The LPN also donned gloves while holding the uncapped needle and administered the insulin without following the correct safety protocols. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the correct procedure for administering insulin includes recapping the needle after drawing the insulin and before bringing it to the patient. The DON expressed that staff should always recap the syringe after drawing up insulin, indicating a lapse in following established safety protocols. This deficiency was observed during a survey, and the facility's failure to adhere to proper pharmaceutical procedures was documented.
Improper Antibiotic Use for Viral Infection
Penalty
Summary
The facility did not ensure proper antibiotic use for a resident who was prescribed an antibiotic prior to obtaining a respiratory panel. The respiratory panel results documented that the resident was infected with the para-influenza virus, which does not respond to antibiotics. Despite this, the resident continued to receive antibiotic treatment without documented follow-up with the prescribing physician regarding the respiratory panel results. The resident, who had diagnoses including Alzheimer's disease, hypertensive heart disease, major depressive disorder, and anxiety disorder, was admitted to the facility and later exhibited symptoms such as cough and congestion. The physician ordered a course of Azithromycin and a respiratory panel. The respiratory panel confirmed the presence of the para-influenza virus, but there was no documentation that the physician was informed of these results or that the antibiotic treatment was reassessed. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility uses McGeer's criteria to identify infections and typically would not treat a viral infection with antibiotics. However, there was no documentation to support that the physician was made aware of the respiratory panel results or the rationale behind continuing the antibiotic treatment. The surveyor noted the lack of follow-up and documentation as a deficiency in the facility's management of the resident's drug regimen.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility did not ensure that its medication error rate was below 5 percent. During the observation of medication administration, staff made errors with two residents out of seven observed, resulting in an error rate of 6.45%. One resident was administered expired Novolin insulin, and another resident was given Aspirin with an illegible expiration date. The facility's policy requires that outdated or contaminated medications be removed and disposed of properly, and that insulin be labeled with a discard date. However, these protocols were not followed in these instances. For the first resident, the LPN administered 30 units of Novolin insulin that had been opened beyond the manufacturer's expiration period of 42 days. The Director of Nursing confirmed that the insulin should not have been administered. For the second resident, the LPN administered an 81 mg chewable Aspirin tablet from a bottle with an illegible expiration date. The Director of Nursing confirmed that the medication should have been discarded if the expiration date was not readable. Both incidents indicate a failure to adhere to the facility's medication administration policies, leading to a medication error rate above the acceptable threshold.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored and labeled according to professional principles. Surveyors observed multiple instances of undated, opened eye drops, unlabeled medications, and expired insulin in the medication carts. Additionally, insulin that required refrigeration was found unrefrigerated, and medications were improperly stored in latex gloves. A salad was also found in the medication fridge, which is against the facility's policy for medication storage. In the 2 Northwest Medication Room, surveyors found a tube of Procto Med HC and Hydrocortisone cream stored inside latex gloves, and a salad in the medication fridge. The refrigerator thermometer read 55 degrees, which is above the acceptable range for medication storage. Expired medications, including Lactulose and house stock bottles of Tab A Vite and Docusate Calcium, were also found. An open bottle of Pepsi and an open bag of Hot Stuff potato chips were observed on the counter behind the sink. The facility's Medication and Vaccine Storage policy states that medications should be stored safely, securely, and properly, with outdated or contaminated medications removed and disposed of properly. The policy also specifies that medications requiring refrigeration should be kept at temperatures between 36 F and 46 F. The surveyor's findings indicate that the facility did not adhere to these guidelines, leading to the observed deficiencies.
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 768 citations issued within 25 miles in the last 12 months — including the 16 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
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 Wauwatosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Anne's Salvatorian Campus | 2 mi | ★★★★★ | 2 | 0 |
| St Camillus Health Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Milwaukee Health And Rehab | 2.9 mi | ★★★★★ | 14 | 0 |
| Luther Manor | 3.1 mi | ★★★★★ | 17 | 0 |
| Resolve At West Allis Respiratory And Rehab | 3.2 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lutheran Home.
100% money-back within 48 hours.
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.