American Lutheran Home-mondovi

Inspection findings

1. May 7, 2026 Health · 5 findings
   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 1, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Jun 1, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 1, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 1, 2026 · CMS fire safety

2. Mar 12, 2025 Fire Safety · 9 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     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 Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Apr 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Apr 24, 2025 · CMS fire safety

3. Feb 14, 2024 Health · 7 findings
   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 6, 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 Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Mar 8, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 8, 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 Mar 8, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BERG, MATTHEW — adp of the snf, NOT APPLICABLE, since 07/01/2016
• DUHR, AMY — operational/managerial control, NOT APPLICABLE, since 01/17/2020
• DUHR, AMY — adp of the snf, NOT APPLICABLE, since 01/17/2020
• DUHR, AMY — corporate officer, NOT APPLICABLE, since 01/17/2020
• ERICKSON, JOANNE — corporate director, NOT APPLICABLE, since 05/30/2023
• GROSSIER, STEPHANY — corporate director, NOT APPLICABLE, since 05/30/2024
• HUNGERFORD, KEVIN — operational/managerial control, NOT APPLICABLE, since 06/01/2025
• LARSON, DAVID — corporate director, NOT APPLICABLE, since 05/30/2021
• LARSON, JAMIE — adp of the snf, NOT APPLICABLE, since 08/24/2021
• LARSON, JAMIE — corporate officer, NOT APPLICABLE, since 08/24/2021
• LARSON, JAMIE — operational/managerial control, NOT APPLICABLE, since 08/24/2021
• LARSON, LINDA — corporate director, NOT APPLICABLE, since 01/28/2025
• LEE, RITA — corporate director, NOT APPLICABLE, since 05/30/2018
• LILYQUIST, JENNY — operational/managerial control, NOT APPLICABLE, since 01/26/2017
• LILYQUIST, JENNY — adp of the snf, NOT APPLICABLE, since 01/26/2017
• LISOWSKI, TONYA — operational/managerial control, NOT APPLICABLE, since 07/12/2016
• LISOWSKI, TONYA — adp of the snf, NOT APPLICABLE, since 07/12/2016
• REID, ANITA — corporate director, NOT APPLICABLE, since 05/30/2023
• RICH, TREVOR — operational/managerial control, NOT APPLICABLE, since 12/26/2024
• RICH, TREVOR — adp of the snf, NOT APPLICABLE, since 12/26/2024
• TANDE, CHELSEA — operational/managerial control, NOT APPLICABLE, since 04/26/2022
• GRACE LUTHERAN FOUNDATION, INC. — operational/managerial control, NOT APPLICABLE, since 01/01/2000
• GRACE LUTHERAN FOUNDATION, INC. — adp of the snf, NOT APPLICABLE, since 03/04/2025