Lutheran Home

Inspection findings

1. Jun 10, 2025 Health · 14 findings
   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 10, 2025 · CMS health inspection

   • Not serious Scope/severity B

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jul 10, 2025 · CMS health inspection

   • 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 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jul 10, 2025 · CMS health inspection

   • 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 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Jul 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jul 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Jul 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     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 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0233 Egress Deficiencies

     Install resident room doors of proper design and width.

     Corrected Jul 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Jul 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 10, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 10, 2025 · CMS fire safety

2. Feb 4, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     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 4, 2025 · CMS health inspection

3. Mar 14, 2024 Health · 12 findings
   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Apr 14, 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 Apr 14, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 27, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 27, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 27, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Mar 27, 2024 · 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 Mar 27, 2024 · CMS fire safety

4. Oct 19, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Nov 17, 2023 · CMS health inspection

   • Serious Scope/severity G Complaint

     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 Nov 17, 2023 · CMS health inspection

5. Dec 13, 2022 Fire Safety · 2 findings
   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 6, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Jan 6, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BUKOWY, ELIZABETH — adp of the snf, NOT APPLICABLE, since 05/20/2014
• BUKOWY, ELIZABETH — operational/managerial control, NOT APPLICABLE, since 05/20/2014
• CAVERS, KATHRYN — corporate officer, NOT APPLICABLE, since 02/01/2012
• CAVERS, KATHRYN — adp of the snf, NOT APPLICABLE, since 02/01/2012
• CAVERS, KATHRYN — operational/managerial control, NOT APPLICABLE, since 02/01/2012
• CLAUSEN, HENRIK — corporate officer, NOT APPLICABLE, since 11/17/2021
• CLAUSEN, HENRIK — adp of the snf, NOT APPLICABLE, since 11/17/2021
• CLAUSEN, HENRIK — operational/managerial control, NOT APPLICABLE, since 11/17/2021
• DENOR, JIM — corporate director, NOT APPLICABLE, since 04/01/2021
• DENOR, JIM — managing control - governing body, NOT APPLICABLE, since 04/01/2021
• EHN, DIANE — managing control - governing body, NOT APPLICABLE, since 10/01/2021
• EHN, DIANE — corporate officer, NOT APPLICABLE, since 10/01/2021
• EHN, DIANE — corporate director, NOT APPLICABLE, since 10/01/2021
• HODAN, MIKE — corporate director, NOT APPLICABLE, since 04/01/2023
• HODAN, MIKE — managing control - governing body, NOT APPLICABLE, since 04/01/2023
• KEBBEKUS, BEN — managing control - governing body, NOT APPLICABLE, since 04/01/2021
• KEBBEKUS, BEN — corporate director, NOT APPLICABLE, since 04/01/2021
• KRIETE, LINDSEY — corporate director, NOT APPLICABLE, since 04/01/2023
• KRIETE, LINDSEY — managing control - governing body, NOT APPLICABLE, since 04/01/2023
• MUELLER, GARY — managing control - governing body, NOT APPLICABLE, since 04/01/2021
• MUELLER, GARY — corporate director, NOT APPLICABLE, since 04/01/2021
• PEDERSEN, HARRIET — corporate director, NOT APPLICABLE, since 04/01/2018
• PEDERSEN, HARRIET — managing control - governing body, NOT APPLICABLE, since 04/01/2018
• PINGEL, LINDSAY — corporate director, NOT APPLICABLE, since 07/21/2025
• PINGEL, LINDSAY — operational/managerial control, NOT APPLICABLE, since 07/21/2025
• PINGEL, LINDSAY — adp of the snf, NOT APPLICABLE, since 07/21/2025
• RAASCH, RANDY — managing control - governing body, NOT APPLICABLE, since 04/01/2023
• RAASCH, RANDY — corporate director, NOT APPLICABLE, since 04/01/2023
• REARDON, TIM — managing control - governing body, NOT APPLICABLE, since 10/01/2019
• REARDON, TIM — corporate director, NOT APPLICABLE, since 10/01/2019
• ROSENBERG, PAUL — managing control - governing body, NOT APPLICABLE, since 10/01/2021
• ROSENBERG, PAUL — corporate director, NOT APPLICABLE, since 10/01/2021
• SANDSTROM, DAVID — corporate director, NOT APPLICABLE, since 10/01/2021
• SANDSTROM, DAVID — corporate officer, NOT APPLICABLE, since 10/01/2021
• SANDSTROM, DAVID — managing control - governing body, NOT APPLICABLE, since 10/01/2021
• SURMA, KRISTINA — corporate director, NOT APPLICABLE, since 10/01/2021
• SURMA, KRISTINA — managing control - governing body, NOT APPLICABLE, since 10/01/2021
• SURMA, KRISTINA — corporate officer, NOT APPLICABLE, since 10/01/2021
• SWARTZ BARTLETT, CAREY — operational/managerial control, NOT APPLICABLE, since 04/14/2014
• SWARTZ BARTLETT, CAREY — adp of the snf, NOT APPLICABLE, since 04/14/2014
• TETTENBORN, JAYNE — adp of the snf, NOT APPLICABLE, since 06/14/2021
• TETTENBORN, JAYNE — operational/managerial control, NOT APPLICABLE, since 06/14/2021
• TRISKA WIEMER, KATIE — corporate director, NOT APPLICABLE, since 04/01/2023
• TRISKA WIEMER, KATIE — managing control - governing body, NOT APPLICABLE, since 04/01/2023
• SEASONS HOSPICE & PALLIATIVE CARE OF WISCONSIN, LLC — adp of the snf, NOT APPLICABLE, since 07/15/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 04/29/2014