Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Care Center during CMS and state inspections, most recent first.
A resident with a history of falls and requiring assistance for transfers sustained a wrist fracture after attempting to self-transfer. The motion alarm, a key intervention in the resident's care plan, was not turned on, contributing to the fall. Staff interviews confirmed the alarm was missed by accident, and the facility's policy on motion alarms was not followed.
A resident with minimal cognitive deficits sustained a skin tear during an interaction with a CNA, who used inappropriate language in response to the resident's accusations. The incident was not immediately reported, and an investigation later substantiated verbal abuse due to the CNA's admission of cursing.
A resident with a history of cognitive deficits sustained a skin tear after a CNA allegedly twisted his arm. The incident was not immediately reported to the facility's Abuse Coordinator, as staff believed it was accidental. The resident reported the incident to the ER, leading to a police investigation. The facility's policy requires immediate reporting of suspected abuse, which was not followed. The verbal abuse was substantiated due to the CNA's inappropriate language.
A resident with Alzheimer's and high fall risk fell and sustained injuries due to inadequate supervision during toileting. Despite being assessed as needing assistance, the resident was left alone on a bedside commode by two CNAs, resulting in a fall while attempting to self-transfer. The incident occurred during a busy period, and the resident's inconsistent use of the call light contributed to the lack of timely assistance.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling catheters and wounds. Observations showed a lack of signage and staff awareness regarding EBP protocols, despite the presence of conditions requiring such precautions. Interviews revealed that the Infection Preventionist and nursing staff were unaware of the criteria for EBP, leading to inadequate infection control measures.
Failure to Activate Motion Alarm Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to follow implemented fall interventions for a resident, resulting in the resident sustaining a fracture of the distal left radius. The resident, who was cognitively intact with a BIMS score of 13, had a history of falls and required substantial assistance for transfers. The care plan for the resident included a motion alarm to alert staff of self-transfers, which was not turned on at the time of the incident. On the day of the incident, the resident was found sitting on the floor by the bed after attempting to self-transfer to the bathroom. The motion alarm, which was supposed to be in place as a fall intervention, was not turned on, and the resident's room door was closed, which contributed to the fall. The resident complained of pain in the left wrist, and an x-ray confirmed a fracture of the distal left radius. Interviews with staff revealed that the motion alarm was missed by accident when the CNA assisted the resident to bed. The facility's policy required motion alarms to be turned on for residents at high risk for falls, but this was not adhered to in this case. The deficiency was identified as a failure to ensure the motion alarm was activated, which was a critical intervention for the resident's safety.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident with a history of Major Depressive Disorder, Hypertension, and Cerebral Infarction, who was noted to have minimal cognitive deficits. The resident sustained a large skin tear on the left forearm, which was reported to have occurred when the CNA attempted to move the resident's wheelchair. The resident accused the CNA of twisting his arm, which the CNA denied, leading to a verbal altercation where the CNA used inappropriate language. The incident was documented in the nurse's notes and witness statements, revealing that the CNA became overwhelmed by the situation and cursed at the resident. Another staff member corroborated hearing the CNA yelling and using inappropriate language towards the resident. The resident, when interviewed, confirmed the incident but did not recall being yelled at or called names. The resident was sent to the emergency room for treatment of the skin tear and returned to the facility the same night. The facility's abuse policy was violated due to the CNA's use of inappropriate language, which was considered verbal abuse. The Licensed Practical Nurse (LPN) involved did not report the incident immediately, as she believed the CNA's explanation and the resident's earlier confusion. The facility's administrator was only informed of the incident after the police contacted the facility, prompting an investigation. The investigation concluded that while physical abuse was unfounded, verbal abuse was substantiated due to the CNA's admission of cursing in front of the resident.
Failure to Report Alleged Abuse and Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident verbal and physical abuse to the facility's Abuse Coordinator. The incident involved a resident with a history of major depressive disorder, hypertension, and cerebral infarction, who was admitted to the facility with minimal cognitive deficits. On the day of the incident, the resident sustained a large skin tear on the left forearm, which was reported by a Licensed Practical Nurse (LPN) after being informed by a Certified Nursing Assistant (CNA) that the resident's wheelchair had been pulled back, causing the injury. The resident alleged that the CNA had grabbed and twisted his arm, leading to the skin tear. The incident was not immediately reported to the facility's Abuse Coordinator, as the LPN believed the injury was accidental and attributed the resident's confusion to his earlier state. The CNA involved in the incident admitted to cursing in front of the resident during the event, which was later confirmed by another staff member who overheard the exchange. The resident was sent to the emergency room for treatment, where the allegation of abuse was reported to the police, prompting an investigation by the facility. The facility's policy requires immediate reporting of any suspected abuse, neglect, or exploitation to the nursing home administrator. However, the staff involved did not adhere to this policy, as they did not report the incident to the administrator until after the police were involved. The facility's Abuse Coordinator later determined that the physical abuse allegation was unfounded, but the verbal abuse was substantiated due to the CNA's inappropriate language in front of the resident.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately supervise a confused resident, identified as R32, during toileting, which resulted in a fall and subsequent injuries. R32, who has a history of Alzheimer's Disease, Diabetes Type 2, and other significant health conditions, was assessed as being at high risk for falls. The resident's care plan indicated the need for supervision during toileting due to poor safety awareness and moderate cognitive deficits. On the morning of the incident, two CNAs assisted R32 onto a bedside commode and left the room, instructing the resident to use the call light when finished. However, R32 attempted to self-transfer back to bed, resulting in a fall that caused a laceration to the forehead requiring 13 sutures and skin tears to the right hand. The CNAs involved acknowledged that the resident's ability to use the call light was inconsistent, and the incident occurred during a busy time when many residents required assistance. The Director of Nurses was not familiar with the specific details of the fall but was aware that staff had been educated to respond promptly to R32's call light. The facility's Fall Prevention Policy aimed to identify residents at risk and initiate preventative measures, but these were not effectively implemented in R32's case, leading to the accident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow enhanced barrier precautions for eight residents who were reviewed for infection control. During an initial tour, it was observed that several residents with indwelling catheters did not have signage indicating they were on Enhanced Barrier Precautions (EBP), despite having conditions that warranted such precautions. The facility's documentation, including the Matrix for Providers (Form CMS 802), did not accurately reflect the residents who required transmission-based precautions. Only one resident was noted to have signage for EBP, and this was due to a MRSA infection. Interviews with facility staff revealed a lack of awareness and understanding of EBP requirements. The Infection Preventionist and other nursing staff were unaware that residents with wounds and indwelling medical devices should be on EBP. This lack of knowledge extended to the Director of Nursing, who was also unaware of the EBP criteria. The facility's failure to implement proper infection control measures was evident in the absence of appropriate signage and the staff's unfamiliarity with EBP protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Altamont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of St. Elmo | 5.3 mi | — | 3 | 0 |
| Effingham Healthcare & Senior Living | 11.3 mi | — | 4 | 0 |
| Lakeland Rehab & Healthcare Center | 11.9 mi | — | 10 | 0 |
| Evergreen Nursing & Rehab Center | 12 mi | — | 4 | 0 |
| Fayette County Hospital | 19.4 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.