Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Nursing Home during CMS and state inspections, most recent first.
A facility failed to report a resident-to-resident altercation as suspected abuse according to its own policy and regulatory requirements. A resident with dementia and severe cognitive impairment exhibited aggressive behavior, including hitting another cognitively impaired resident, attempting to enter another resident’s room with family present, and attacking staff. An LPN documented the behaviors and notified the resident’s family and physician but did not clearly notify the administrator or DON, and no report was made to the state agency. Staff interviews showed that CNAs and LPNs understood that resident-to-resident altercations should be reported immediately, yet the administrator and DON stated they were never informed. The LPN later acknowledged sending a vague text to the DON describing the residents as having hit each other and being “grumpy old ladies,” expressed uncertainty about whether the event constituted abuse because there was no injury, and the incident was never formally reported as required.
The facility failed to investigate a resident-to-resident altercation involving a cognitively impaired resident with dementia and agitation who exhibited aggressive behaviors, including hitting another cognitively impaired resident, attempting to lock themself in another resident’s room while family was present, and attacking staff by punching, spitting, and attempting to bite. An LPN documented the incident and notified the resident’s son and physician, and staff acknowledged that abuse allegations require investigation by the Administrator. However, the DON and Administrator reported they were never informed of the altercation and no investigation, as required by the facility’s abuse and investigation policy, was initiated or completed.
A resident with a prosthetic heart valve and recent hospitalization for anticoagulation issues was admitted on warfarin 5 mg daily, but no INR lab orders were entered or completed despite hospital discharge instructions calling for an early INR check and weekly monitoring. The facility’s anticoagulation policy required identification of anticoagulated residents, review of recent labs, and close INR monitoring for those on warfarin. Staff interviews showed that the ADON, who was responsible for entering admission and lab orders into the EMR and lab system, did not enter INR orders and had since left employment, and there was no process to verify that all admission orders were in place. The DON confirmed that the resident had no INR testing during the stay, and the physician stated that all discharge instructions, including INR monitoring, were expected to be followed.
A resident with dementia and generalized anxiety disorder exhibited frequent and escalating aggressive behaviors, including hitting, kicking, spitting, using racial slurs, and attacking other residents and staff, often requiring 1:1 observation and extensive redirection. Despite these ongoing incidents, the resident’s behavior care plan and goals had not been updated for an extended period and continued to list only general interventions, while staff reported the resident was no longer easily redirectable and had increased aggression and restlessness. Behavioral monitoring orders were not initiated until months after aggressive behaviors were documented, and even after initiation, MAR/TAR entries frequently indicated no behaviors on days when progress notes and staff interviews described significant aggression, including an episode where the resident pulled a gate off its hinges and struck a nurse in the face. CNAs and nurses reported limited or no access to care plans, lack of education on managing behaviors, inconsistent documentation of behaviors, and a perception that management did not act on reported behaviors, resulting in inaccurate behavioral monitoring and an out-of-date care plan that did not reflect the resident’s current status or effective interventions.
A resident with Alzheimer's and mobility issues was transferred by a CNA without the required assistance or a gait belt, contrary to the care plan. The CNA acted alone due to the resident's agitation and lack of immediate help, resulting in the resident falling onto the bed. Interviews confirmed the CNA was aware of the proper procedures but did not follow them.
The facility failed to honor the bathing preferences of three residents, leading to a deficiency in treating them with dignity and self-determination. A resident with a stage IV pressure ulcer preferred whirlpool baths but often received bed baths, feeling unclean and uncomfortable. Another resident preferred daily showers but only received one bath per week, while a third resident felt embarrassed due to infrequent bathing. Staff interviews revealed inconsistencies in the facility's bathing schedule and a lack of awareness of residents' preferences, contributing to the deficiency.
Failure to Report Resident-to-Resident Altercation as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report a resident-to-resident altercation as suspected abuse in accordance with its abuse, neglect, exploitation, and misappropriation reporting policy. The facility’s policy, dated September 2022, required that all reports of resident abuse be immediately reported to the administrator and other officials, including the state survey agency, ombudsman, resident representative, law enforcement, attending physician, and medical director, within specified timeframes (within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations). The policy also required that notices include the residents’ names, room numbers, type of alleged abuse, date and time of the incident, persons involved, and immediate actions taken. Resident #3, who had a diagnosis of unspecified dementia with agitation and severely impaired cognition per a quarterly MDS, was documented in a Health Status Note on 2/20/26 at 9:10 P.M. by LPN C as having aggressive behaviors that day, including hitting another resident, attempting to lock themself in another resident’s room while family was present, and attacking staff (punching, spitting, and attempting to bite). Resident #14, who had a diagnosis of early-onset Alzheimer’s disease and moderately impaired cognition per a quarterly MDS, was later identified as the other resident involved in the altercation. The note indicated that LPN C notified Resident #3’s son and physician after the altercation, but there was no documentation of notification to the administrator or DON, and no report was made to the state agency as required by policy. Interviews revealed confusion and inconsistency regarding reporting responsibilities and whether the incident constituted abuse. A CNA stated that any resident-to-resident altercation, verbal or physical, needed to be reported immediately to the nurse and/or DON. Another LPN stated that all resident-to-resident altercations needed to be reported immediately to the administrator or DON and that the facility had two hours to report abuse allegations to the Department of Health and Senior Services, but believed LPN C had likely informed leadership despite the lack of documentation. The administrator and DON stated they had not been informed of the altercation and therefore did not report it. In a phone interview, LPN C recalled the incident after reviewing the note, stated that Resident #3 had been involved in prior altercations, and acknowledged sending a text to the DON indicating that the two residents had hit each other again and were “just grumpy old ladies” with no injuries. LPN C expressed uncertainty about whether the altercation counted as abuse, believing abuse required malintent and injury, and acknowledged the text might not have clearly conveyed that one resident had hit the other. As a result, the incident was not treated or reported as suspected abuse in accordance with facility policy and regulatory requirements.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to conduct an investigation after a resident-to-resident altercation. Facility policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, required that all allegations be thoroughly investigated, with the Administrator initiating or assigning the investigation to a trained individual. The policy specified that the investigation must include review of documentation and evidence, review of the resident’s medical record and cognitive/physical status, observation of the alleged victim, interviews with the reporter, the resident or representative, physician as needed, staff on all shifts, roommates, family, and visitors, review of events leading up to the incident, and complete documentation of the investigation. Despite this, a Health Status Note dated 2/20/26 at 9:10 p.m. by an LPN documented that a resident with severely impaired cognition and dementia with agitation had aggressive behaviors that day, hit another resident, attempted to lock themself in another resident’s room while family was present, and attacked staff by punching, spitting, and attempting to bite. The resident who was hit had a diagnosis of early-onset Alzheimer’s disease with moderately impaired cognition. The LPN documented that the aggressive resident’s son and physician were notified after the altercation. Staff interviews confirmed that when an allegation of abuse is reported, an investigation is required and that the Administrator is responsible for completing abuse investigations, although one LPN was unsure of the required timeframe. During interviews, the DON and Administrator stated they had not been informed of the resident-to-resident altercation on 2/20/26, did not complete an investigation related to that incident, and acknowledged that an investigation should have been completed. No evidence was presented that any of the investigative steps outlined in the facility’s policy were carried out for this altercation.
Failure to Implement INR Monitoring Orders for Resident on Warfarin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that INR testing was ordered and completed for a resident receiving warfarin therapy, as required by professional standards and the facility’s own anticoagulation policy. The resident was admitted with diagnoses including cognitive symptoms following a nontraumatic subarachnoid hemorrhage and the presence of a prosthetic heart valve, and had an active order for warfarin 5 mg by mouth in the evening. The resident’s care plan identified anticoagulant therapy with an intervention for labs and diagnostics as ordered, and the hospital discharge summary documented that the resident had a high INR upon hospital admission and required an INR check early the following week after admission to the facility, with weekly INR checks for several weeks. Review of the resident’s order summary showed no INR test orders in place, and the DON confirmed that no INR testing had been completed while the resident was at the facility. Interviews with facility staff revealed that the ADON was responsible for entering all admission orders, including lab orders, into the EMR and the lab ordering system, but the ADON no longer worked at the facility. The DON stated there was no process for anyone to verify that all admission orders were correctly entered after the ADON, and was unsure why all of the resident’s admission orders were not in the EMR. The unit manager reported not having seen the resident’s discharge paperwork but stated that, based on the instructions, he or she would have entered INR testing orders and contacted the physician to confirm. RN A stated that he or she was not responsible for entering admission orders. The attending physician reported expecting the facility to follow all discharge instructions, including placing INR orders into the EMR, and stated that the resident should have had weekly INR orders in place given the resident’s history and hospital course. The facility’s anticoagulation policy required identification of anticoagulated residents, review of recent labs and therapeutic monitoring, and close INR monitoring for residents on warfarin, but this process was not carried out for this resident.
Failure to Maintain Accurate Behavioral Monitoring and Updated Care Plan for Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate behavioral monitoring and care planning for a resident with dementia and generalized anxiety disorder who exhibited frequent and escalating aggressive behaviors. The resident was admitted with unspecified dementia with agitation and later diagnosed with generalized anxiety disorder. Multiple Health Status Notes documented episodes of aggression, including yelling at and pushing other residents, hitting and punching staff, kicking, spitting, attempting to bite, and using racial slurs. On several occasions, the resident was described as combative for extended periods, unable to be redirected, refusing meals, and requiring 1:1 observation to prevent confrontations with other residents. Staff notes also described the resident attempting to lock themselves in another resident’s room, attacking a nurse and CNA, and hitting another resident with a plastic hanger. Despite these documented behaviors, the resident’s care plan for mood and behavior had not been updated since 2024, even though the resident’s behaviors had increased in frequency and severity in the months leading up to the survey. The care plan listed general interventions such as administering medications as ordered, monitoring for side effects, approaching the resident calmly, assessing for toileting, hunger, thirst, and pain, and calling the resident by name, and noted that the resident was usually redirectable. These interventions and goals were not revised to reflect the more recent pattern of increased aggression, difficulty with redirection, and the need for 1:1 observation. The MDS Coordinator confirmed that no other staff were involved in care plans, that the care plan could have been more specific, and that the resident’s care plan was not up to date and did not reflect the resident’s current status. The facility also failed to implement and document consistent behavioral monitoring in accordance with its own policy and the physician’s orders. An order for behavioral monitoring, including specific behaviors such as hitting, kicking, spitting, cussing, racial slurs, aggression, and refusing care, was not put in place until late March, despite months of documented aggressive incidents. After the order was initiated, the MAR/TAR for March and April showed no behaviors on multiple days, even though progress notes and staff interviews described frequent aggression and restlessness. Nursing staff, including an LPN, admitted they were not good at charting behaviors, often marked “N” for no behaviors regardless of what occurred, and stated that nurse management did not act on the information when behaviors were documented. The DON and Administrator acknowledged that the resident’s care plan was not current, that behavioral monitoring had not been ordered prior to late March, and that the April MAR/TAR was not accurate, including a failure to mark behaviors on the day the resident pulled a gate off its hinges and struck a nurse in the face, causing a bloody lip. Interviews with CNAs and nurses further demonstrated gaps in behavioral health care and monitoring. CNAs reported that the resident was aggressive more than once a week, with increased behaviors and more physical contact in the last two months, and that the resident’s behaviors were a day-to-day issue. Several CNAs and an LPN stated they did not have access to care plans or that care plans were not up to date or accurate. One NA reported not being educated on how to manage behaviors and primarily using the strategy of leaving the resident alone when aggressive. An LPN and other staff expressed that staff on the special care unit were not adequately prepared or educated to work with residents with significant behavioral symptoms. Collectively, these observations show that the facility did not maintain accurate behavioral monitoring documentation, did not update the care plan to reflect the resident’s escalating behaviors and effective interventions, and did not ensure staff were adequately informed and trained to implement individualized behavioral interventions as required by the facility’s own behavioral assessment and monitoring policy.
Failure to Follow Transfer Protocols for Resident with Alzheimer's
Penalty
Summary
The facility staff failed to adhere to the established policy and the resident's care plan by transferring a resident without the required assistance and equipment. The resident, who had Alzheimer's disease, muscle weakness, abnormal gait, and a history of repeated falls, required assistance with activities of daily living, including transfers. The care plan specified that one to two staff members should assist with transfers and that a gait belt should be used. On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a wheelchair to a bed without using a gait belt or obtaining assistance from another staff member. The resident was agitated, flailing arms, and yelling, which led the CNA to act quickly to calm the resident by placing them in bed. Despite knowing the resident's transfer requirements, the CNA proceeded alone, resulting in the resident falling onto the bed. Interviews with the CNA, a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the facility Administrator revealed that the CNA was aware of the need for assistance and a gait belt but chose to proceed due to the resident's agitation and lack of immediate help. The CNA admitted to not having a gait belt and not waiting for assistance, while the LPN and DON confirmed that the CNA should have followed the care plan and physician's orders.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of three residents, leading to a deficiency in treating them with dignity and self-determination. Resident #1, who was cognitively intact and had a stage IV pressure ulcer, preferred whirlpool baths but often received bed baths due to wound care needs. The resident expressed dissatisfaction with the frequency and quality of baths, feeling unclean and uncomfortable, and had specific preferences regarding staff and timing, which were not consistently respected. Interviews revealed that staff were unaware of the resident's preferences, and the Director of Nursing (DON) was not informed of any complaints. Resident #3, also cognitively intact, preferred more frequent bathing than the once-a-week schedule provided by the facility. The resident expressed a desire for daily showers, as was their routine before entering the facility. Similarly, Resident #4, who required assistance with activities of daily living, preferred more frequent baths, especially during warmer months, but only received one bath per week. This resident felt embarrassed and believed the facility was understaffed, affecting the ability to meet bathing preferences. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the facility's bathing schedule and a lack of awareness of residents' preferences. The facility policy stated residents should receive two baths per week, but staffing issues often led to only one bath per week. The Administrator acknowledged the facility's policy of once-a-week baths and the challenges in accommodating additional requests. Despite the facility's policy and residents' expressed preferences, the care plans did not adequately reflect or ensure adherence to these preferences, contributing to the deficiency.
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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 Concordia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meyer Care Center | 10.8 mi | — | 1 | 0 |
| Apple Ridge Care Center | 15.7 mi | — | 3 | 0 |
| Country Club Rehab And Healthcare Center | 17.2 mi | — | 0 | 0 |
| Warrensburg Manor Care Center | 17.3 mi | — | 0 | 0 |
| Johnson County Care Center | 17.9 mi | — | 17 | 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.