Inspection visit
Inspection
Citations
29 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0030GeneralS&S Epotential for harm
List the names and contact information of those in the facility.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0200GeneralS&S Fpotential for harm
Meet other general requirements.
- 0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0331GeneralS&S Fpotential for harm
Construct fire resistant interior walls.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F921 - Other Environmental Conditions
Ensure that testing and maintenance of electrical equipment is performed.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
FAQ · About this visit
Common questions about this visit
What happened during the January 23, 2025 survey of Lakeside Lutheran Home?
This was a inspection survey of Lakeside Lutheran Home on January 23, 2025. The surveyor cited 29 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Lakeside Lutheran Home on January 23, 2025?
Yes, 29 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Include a process for Emergency Preparedness collaboration."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.