St. John Lutheran Home

Inspection findings

1. Jun 3, 2026 Health · 10 findings
   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 24, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 24, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Jul 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jul 24, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Jul 15, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 31, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Jul 15, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 31, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jul 31, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jul 31, 2026 · CMS fire safety

2. May 14, 2025 Health · 12 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jun 6, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 6, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 13, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Jun 4, 2025 · CMS fire safety

3. Apr 17, 2024 Health · 8 findings
   • Not serious Scope/severity B

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jun 7, 2024 · CMS fire safety

4. Aug 4, 2022 MDH complaint investigation · 3 findings
   • Severity not stated

     H54073515C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H54073595C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H54073596C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Jul 6, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H54072673C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. Mar 31, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H5407036C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Apr 20, 2021 MDH complaint investigation · 1 finding
   • Severity not stated

     H5407022C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

8. Dec 3, 2020 MDH complaint investigation · 2 findings
   • Severity not stated

     H5407019C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5407020C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Nov 30, 2020 MDH complaint investigation · 1 finding
   • Severity not stated

     H5407017C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

10. Nov 3, 2020 MDH complaint investigation · 2 findings
    • Severity not stated

      H5407014C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H5407015C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• ASMUS, JUSTIN — corporate director, NOT APPLICABLE, since 05/23/2022
• BEYER, LINDSEY — corporate director, NOT APPLICABLE, since 05/23/2022
• BEYER, LINDSEY — operational/managerial control, NOT APPLICABLE, since 05/23/2022
• GROFF, JANET — corporate director, NOT APPLICABLE, since 05/23/2022
• LERNER, BRACEY — corporate director, NOT APPLICABLE, since 05/23/2022
• MATTSON, TRICIA — corporate director, NOT APPLICABLE, since 05/23/2022
• MEINE, MAXINE — corporate director, NOT APPLICABLE, since 05/23/2022
• MEYER, WILLIS — corporate director, NOT APPLICABLE, since 05/23/2022
• ROSALES, MELISSA — corporate director, NOT APPLICABLE, since 05/23/2022
• ROSALES, MELISSA — operational/managerial control, NOT APPLICABLE, since 05/23/2022
• VOGE, KAREN — corporate director, NOT APPLICABLE, since 05/23/2022
• WELLNER, DENISE — corporate director, NOT APPLICABLE, since 05/23/2022
• WENDT, PAMELA — corporate director, NOT APPLICABLE, since 05/23/2022