Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of personal fund accounts, observation, resident and staff interview, and review of facility
policy, the facility failed to ensure residents had access to personal funds. This affected one (#39) out of 26
residents with personal fund accounts. The facility census is 58.
Residents Affected - Few
Findings include:
Review of the personal fund accounts revealed Resident #39 had an account managed by the facility.
Review of the most recent quarterly statement revealed as of 06/27/22 Resident #39's remaining balance
was $29.95.
Observation on 06/27/22 at 12:27 P.M. revealed Resident #39 requested $10 of personal funds from
Activities Assistant #429. Activities Assistant #429 asked numerous questions to Resident #39 of why she
needed the money and what she planned to purchase. Resident #39 avoided the question for a couple of
instances and made a short joking remark. Activities Assistant #429 stated the Business Office Manager
was out that day and Resident #38 could not obtain her funds until tomorrow. Medical Records Clerk #432
offered to loan Resident #39 $10 until the next day.
Interview on 06/27/22 at 12:30 P.M. with Resident #39 verified she was told she could not access $10 from
her account because the Business Office Manager was out of the building.
Interview on 06/27/22 at 1:31 P.M. with Activities Assistant #429 verified telling Resident #39 the Business
Office Manager was out of the office and she could not access her money. Activities Assistant #429
reported Resident #39 had an appointment with transportation and often attempts to get the driver to stop
so she can purchase candy. Activities Assistant #429 reported Resident #39 has diabetes and should not
eat candy.
Interview on 06/30/22 at 10:53 A.M. with Business Office Manager #434 verified she was not working on
06/27/22. Business Office Manager #434 stated there is a process in place to ensure residents have
access personal funds at all times, even when she is out of the office.
Review of the facility policy titled Resident Funds, revised June 2020, revealed the facility will provide a
means for the resident to access his or her funds.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 16
Event ID:
366162
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, and review of facility policy, the facility failed to provide
privacy when clipping a resident's toe nails for one (#313) resident randomly observed. The facility census
was 58.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #313 was admitted on [DATE]. Diagnosis included
Alzheimer's disease, major depressive disorder, and dementia.
Observation on 06/28/22 at 10:55 A.M. revealed Licensed Practical Nurse (LPN) #455 clipping Resident
#313's toe nails in the resident common area. Residents also present in the common area included
Resident #8, #22, #34, #35, #40, #56, and #59.
Interview on 06/28/22 at 11:11 A.M. with Licensed Practical Nurse (LPN) #455 verified clipping Resident
#313's toe nails in the common area.
Review of facility policy titled Quality of Life, created on 11/13/17, revealed the resident shall be cared for in
a manner that is respectful and dignified in recognition of their individuality.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 2 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed
report to the State Survey Agency an allegation when a resident intentionally poured water onto a confused
resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58.
Findings include:
Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included
borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular
disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively
intact.
Review of Resident #39's progress notes revealed the record was silent of any resident to resident
interactions.
Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she
had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago
Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated
Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave
her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on
Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on
another resident and she was instructed to next time use her call light.
Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes
anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication
deficit, and unsteadiness on feet.
Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired.
Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was
intermittently wandering the unit and at times attempting to go into other resident rooms. One on one
redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into
other rooms. Staff monitoring resident to attempt to prevent incident.
Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about
an incident between Resident #39 and Resident #54 about two to three weeks ago.
Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the
incident.
Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to
resident altercation between Resident #39 and Resident #54.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 3 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN)
Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an
unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the
Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They
determined a self-reported incident was not required because there was no intent to harm.
Residents Affected - Few
Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident
#39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave
her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident
#54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and
Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the
on-call manager to report the concern.
Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident
Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or
punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of
willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or
harm. The an allegation of abuse should be reported to the Ohio Department of Health (ODH) immediately,
but not later than twenty four hours after the allegation is made.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 4 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed
investigate an allegation when a resident intentionally poured water onto a confused resident. This affected
two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58.
Residents Affected - Few
Findings include:
Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included
borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular
disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension.
Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively
intact.
Review of Resident #39's progress notes revealed the record was silent of any resident to resident
interactions.
Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she
had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago
Resident #54 came into her room and Resident #39 had told her to leave repeatedly. Resident #39 stated
Resident #54 would not leave and continued to state she wanted a shower. Resident #39 stated she gave
her what she wanted by sprinkling Resident #54 with water then dumping the rest of the cup of water on
Resident #54. Resident #39 reported facility staff were upset with her at the time for dumping water on
another resident and she was instructed to next time use her call light.
Review of Resident #54's medical record revealed an admission dated of 02/21/17. Diagnoses includes
anoxic brain damage, type two diabetes, irritability and anger, violent behavior, cognitive communication
deficit, and unsteadiness on feet.
Review of the MDS assessment, dated 05/21/22, revealed the resident was severely cognitively impaired.
Review of Resident #54's progress note, dated 05/27/22 at 4:59 P.M., revealed the resident was
intermittently wandering the unit and at times attempting to go into other resident rooms. One on one
redirection and frequent toileting attempts with minimal success were attempted to prevent wandering into
other rooms. Staff monitoring resident to attempt to prevent incident.
Interview on 06/28/22 at 3:19 P.M. with State Tested Nursing Assistant (STNA) #422 verified hearing about
an incident between Resident #39 and Resident #54 about two to three weeks ago.
Interview on 06/28/22 at 3:26 P.M. with Resident #54 revealed the resident had no recollection of the
incident.
Review of Self-Reported Incidents (SRI) for 2022 revealed no SRI had been initiated regarding a resident to
resident altercation between Resident #39 and Resident #54.
Interview on 06/29/22 at approximately 12:00 P.M. with the Administrator and Registered Nurse (RN)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 5 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Regional Nurse #456 verified they were aware of an interaction between Resident #39 and #54 on an
unknown date when Resident #39 splashed water on Resident #54. RN Regional Nurse #456 reported the
Director of Nursing (DON) called the Administrator who had called RN Regional Nurse #456. They
determined a reported the residents were laughing about it and there was no intent to harm therefore an
investigation was not completed.
Residents Affected - Few
Interview on 06/29/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #435 verified on 05/26/22 Resident
#39 dumped approximately 120 cubic centimeter (cc) of water on Resident #54 after she would not leave
her room and repeatedly stated she wanted a shower. LPN #435 reported water was observed on Resident
#54 shirt near the waistband. LPN #435 reported neither resident was upset about the incident and
Resident #39 laughed. LPN #435 stated she did believe it was a resident to resident incident and called the
on-call manager to report the concern.
Review of policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident
Property, reviewed 02/2021, revealed the definition of abuse includes the willful infliction of intimidation or
punishment with resulting physical harm, pain or mental anguish. It includes mental abuse. The definition of
willful meant the individual must have acted deliberately, not that the individual intended to inflict injury or
harm. Once the Administrator is notified an investigation of the allegation violation will be conducted.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 6 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record review and staff interview, the facility failed to transmit Minimum Data Set,
(MDS) assessments for three (#266, #267, and #2) out of 24 residents reviewed for MDS assessments. The
current census was 58.
Residents Affected - Some
Findings include:
1. Review of the medical record for Resident #266 revealed the resident was admitted to the facility on
[DATE]. Diagnoses include hip replacement, cancer, hypertension, and pressure ulcers. The resident was
discharged from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for
Resident #266.
2. Record review for Resident #267 revealed the resident was admitted to the facility on [DATE]. Diagnoses
for Resident #267 include heart disease, renal failure, and thyroid disease. The resident was discharged
from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for
Resident #267.
2. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses
include anemia, hypertension and diabetes. The resident was discharged from the facility in 03/2022.
Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for
Resident #2.
Interview on 06/28/22 at 2:00 P.M. with the Regional Nurse #456 verified the facility had not employed a
MDS nurse since 03/2022. The Regional Nurse #456 verified the MDS assessments had not been
completed and transmitted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 7 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of facility policy, and staff interview the facility failed to complete a baseline care plan
with oxygen included as a focus for three residents, (#264, #34, and #213) out of five residents reviewed for
baseline care plans. The current census is 58.
Findings include:
1. Record review of Resident #264 revealed the resident had been admitted to the facility on [DATE].
Diagnoses for Resident #264 include dementia with behaviors, diabetes, falls, neuralgia, and cognitive
deficit.
Review of Resident #264's Minimum Data Set (MDS) assessment, dated 06/18/22, revealed the resident
had impaired cognition and received supplemental oxygen.
Review of the physician orders dated 06/14/22 revealed the resident was to receive oxygen to maintain
oxygen level above 90 percent.
Review of Resident #264's baseline care plans, dated 06/14/22, revealed no care plan for for oxygen. Per
the care plans dated 06/26/22 the resident had a goal added to the 'basic needs' focus with the intervention
of oxygen as ordered.
Interview on 06/28/22 at 3:14 P.M. with the Registered Nurse (RN) Regional Nurse #456 verified the use of
oxygen was not addressed in the 06/14/22 baseline care plan.
Review of policy titled Comprehensive Care Plan/Baseline, revised October 2018, revealed a baseline care
plan will be initiated within 48 hours of resident being admitted . The baseline care plan will be the
temporary working care plan until the comprehensive care plan is completed.
2. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included
protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication
deficit, osteoarthritis, hypertension, and Alzheimer's disease.
Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired.
Review of Resident #34's record review revealed a baseline care plan had not been completed. The
comprehensive care plan was initially completed on 02/25/22.
Interview on 06/30/22 at approximately 12:30 P.M. with RN Regional Nurse #456 verified a baseline care
plan for Resident #34 could not be located.
3. Review of the medical record for Resident #213 revealed an admission date of 06/22/22. Diagnoses
included chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia.
Review of the current physician orders revealed an order dated 06/22/22 for Resident #213 to have a #6
Shiley uncuffed tracheostomy (trach)in place to maintain patent airway, and to check every
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 8 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
shift. Further review revealed an order dated 06/22/22 for Resident #213 to receive 30% cool aerosol via
trach collar at bedside with oxygen 2 liters per minute via pressure line adapter.
Review of the baseline care plan dated 06/22/22 revealed no care plan for Resident #213's tracheostomy
care or supplemental oxygen.
Residents Affected - Few
Interview on 06/28/22 at 5:06 P.M. with the Director of Nursing (DON) confirmed Resident #213's baseline
care plan did not include care areas for the tracheostomy or supplemental oxygen.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 9 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to complete comprehensive care plans for one (#34) out
of 24 residents reviewed for care plans. The current census was 58.
Findings include:
Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included
protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication
deficit, osteoarthritis, hypertension, and Alzheimer's disease.
Review of Resident #34's comprehensive care plan revealed it wasn't completed until 02/25/22.
Interview on 06/30/22 at approximately 12:30 P.M. with Registered Nurse Regional Nurse #456 verified
Resident #34 was admitted on [DATE] and a comprehensive care plan was not initiated until 02/25/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 10 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident interview, family interview, review of the facility policy, and staff interview, the facility
failed to conduct care conferences with residents and their families. This affected two (#6 and #39) out of
three residents reviewed for care conferences. The facility failed to revise a care plan following the
assessment of one (#34) out of 24 residents reviewed for care plans. The current census was 58.
Findings include:
1. Review of the medical record of Resident #6 revealed the resident was admitted to the facility on [DATE].
Diagnoses included chronic bronchitis, dementia with behaviors, heart disease, weakness, history of
fractures, and depression.
Review of Resident #6's Minimum Data Set (MDS) assessment, dated 06/03/22, revealed the resident had
impaired cognition and behavior, and was a two person assistance with Activities of Daily Living, (ADL).
Further review of Resident #6's medical records revealed there was no documentation of care conferences
being conducted from 06/2021 through 06/2022.
Interview on 06/27/22 at 11:36 A.M. with Resident #6 and her daughter revealed the facility has not
planned, conducted, or discussed the care of the resident with the resident and her daughter on a quarterly
basis. Per Resident #6's daughter she attended care conferences last year but none were scheduled or
offered in 2022. The resident's daughter stated she has requested care conferences with the staff but have
the staff have not honored her request.
Interview on 06/29/22 at 4:00 P.M. with Licensed Social Worker (LSW) #408 verified there was no
documentation in the Resident #6's record for care conferences having occurred. Per the social worker
there had been no care conferences conducted with the team, the resident, and her family since 06/2021.
2. Review of Resident #39's medical record revealed an admission date of 07/11/19. Diagnoses included
borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular
disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, weakness, sleep apnea, lymphedema, and
hypertension.
Review of the MDS assessment, dated 05/09/22, revealed the resident was cognitively intact.
Review of the care plan conferences revealed Resident #39 had not had a care plan conference since
07/02/20.
Interview on 06/29/22 at 4:24 P.M. with LSW #408 revealed on 06/29/22 she documented a care plan
conference with Resident #39 that was held on 04/28/22. LSW #408 verified she has not planned or held
formal care conferences in the past year with any residents. LSW #408 verified if it was not documented
they were not complete.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 11 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
3. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included
protein-calorie malnutrition, acute respiratory failure with hypoxia, cognitive communication deficit,
hyperlipidemia,, hypertension, restlessness and agitation, dementia, type two diabetes mellitus, and
Alzheimer's disease.
Review of the MDS assessment, dated 04/26/22, revealed the resident was cognitively impaired. The
assessment revealed there were no current pressure ulcers.
Review of the comprehensive care plan, initiated on 02/25/22, revealed a current care plan for pressure
ulcers, including a stage three area on the coccyx.
Review of the medical record revealed, dated 03/17/22, revealed the pressure ulcer to the coccyx was
resolved. The care plan was not updated to show the resolved area.
Interview on 06/28/22, at an unknown time, with Registered Nurse (RN) Regional Nurse #456 verified
Resident #34's care plan had not been updated with the resolved pressure ulcer.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 12 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on resident interview, staff interview and record review, the facility failed to obtain orders for the
flushing of a gastrostomy tube (g-tube) upon admission to the facility, failed to provide flushes as ordered by
the physician, and failed to have a policy regarding g-tube care and treatment . This affected one (#213) of
one resident reviewed for a g-tube. The facility census was 58.
Findings include:
Review of the medical record for Resident #213 revealed an admission date of 06/22/22 with diagnoses of
chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia.
Review of physician orders upon admission revealed an order for an oral diet. There were no orders upon
admission for g-tube flushes.
Review of a physician order dated 06/24/22 revealed Resident #213's g-tube should be flushed with 60
milliliters (mL) of water every eight hours to maintain patency.
Review of the treatment administration record (TAR) for Resident #213 revealed g-tube flushes were not
given on 06/24/22 at 10:00 P.M., on 06/25/22 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., on 06/26/22 at 6:00
A.M., on 06/27/22 at 2:00 P.M., on 06/28/22 at 2:00 P.M. and on 06/29/22 at 2:00 P.M.
Interview on 06/27/22 at 11:30 A.M. with Resident #213 revealed he had a g-tube but did not use it for
nourishment or hydration.
The facility was unable to provide a policy regarding g-tube care or treatment.
Interview on 06/30/22 at 10:32 A.M., Assistant Director of Nursing (ADON) #446 confirmed the order for
Resident #213's g-tube flushes started two days after admission. Further interview confirmed flushes were
not documented on eight occasions and she could not provide verification the flushes were given on those
occasions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 13 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, and staff interview, the facility failed to provide oxygen per
physician order for one (#40) out of two residents reviewed for oxygen therapy. The current census was 58.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #40 revealed an admission date of 04/09/20 with medical
diagnoses of dementia, paranoid personality disorder, and insomnia.
Review of the quarterly Minimum Data Set assessment, dated 05/09/22, revealed Resident #40 had
severely impaired cognition, required extensive assistance of one person for bed mobility and transfers, and
limited assistance of one person for toilet use and hygiene.
Review of a physician order dated 10/21/21 revealed Resident #40 received oxygen therapy at 2 liters per
minute (L/min) per nasal cannula every shift as needed for dyspnea and respiratory distress.
Review of the medication administration record (MAR) for Resident #40 dated 06/27/22 through 06/29/22
revealed no documentation of the resident having any dyspnea or respiratory distress and no
documentation oxygen was administered.
Observation on 06/27/22 at 2:49 P.M. revealed Resident #40 sitting in the common area receiving oxygen
via nasal cannula at 3 L/min.
Interview on 06/27/22 at 3:04 P.M. with Licensed Practical Nurse (LPN) #457 confirmed Resident #40's
oxygen was running at 3 L/min.
Interview on 06/27/22 at 5:40 P.M. with LPN #435 revealed a State Tested Nurse Aide (STNA) had applied
Resident #40's oxygen and increased it above the physician's ordered rate. Further interview revealed
STNAs should not adjust oxygen rates.
Observation on 06/28/22 at 9:55 A.M. revealed Resident #40 sitting in the common area receiving oxygen
via nasal cannula at 2 L/min.
Observation on 06/29/22 at approximately 10:00 A.M. revealed Resident #40 sitting in the common area
receiving oxygen via nasal cannula at 2 L/min.
Interview on 06/29/22 at 4:36 P.M. with LPN #410 confirmed Resident #40 had oxygen on earlier in the day
on 06/29/22.
Interview on 06/30/22 at 10:23 A.M. with the Assistant Director of Nursing #446 confirmed Resident #40's
MAR revealed no documentation oxygen was administered 06/27/22 through 06/29/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 14 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Potential for
minimal harm
Based on staff interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides
(STNA) received annual in-services. This affected two (STNA #401 and STNA #414) our of 18 STNAs
employeed and had the potential to affect all 58 residents residing in the facility.
Residents Affected - Many
Findings include:
Review of the personnel files for STNA #401 revealed a hire date of 06/24/13. There was no evidence of the
completion of 12 hours of in-services every 12 months.
Review of the personnel files for STNA #414 revealed a hire date of 04/21/04. There was no evidence of the
completion of 12 hours of in-services every 12 months.
Interview on 06/30/22 at 1:30 P.M. with the Director of Human Resources confirmed the STNAs had not
completed 12 hours of in-services over the last 12 months.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 15 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366162
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/30/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home
1036 South Perry Street
Napoleon, OH 43545
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the
facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect
all 58 residents in the facility.
Residents Affected - Many
Findings include:
Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and
06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21.
Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA
meetings during the third and fourth quarters of 2021.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366162
If continuation sheet
Page 16 of 16
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Back to topCitations
12 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
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.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
FAQ · About this visit
Common questions about this visit
What happened during the June 30, 2022 survey of LUTHERAN HOME?
This was a inspection survey of LUTHERAN HOME on June 30, 2022. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHERAN HOME on June 30, 2022?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.