Salem Lutheran Home
2027 College Avenue, Elk Horn, IA 51531
Salem Lutheran Home is a nursing home in Elk Horn, Iowa. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (712) 764-4201
- Last standard health inspection
- August 13, 2026 (2 months ago)
- Certified beds
- 64
- Residents per day, on average
- 46.5
- Ownership type
- Non profit - Church related
- Legal business name
- American Lutheran Church
- Chain
- Good Samaritan Society
- Takes part in
- Medicare and Medicaid
More health citations than the Iowa average (39 vs 21).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
8 citations
Health inspection on August 13, 2026
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0812 2 times since 2024.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on September 11, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 11, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 11, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0760 2 times since 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0761 2 times since 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0842 3 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 11, 2026.
CMS has cited this home for F0880 4 times since 2024.
3 citations
Fire safety inspection on August 13, 2026
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on August 21, 2026.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 12, 2026.
CMS has cited this home for K0712 2 times since 2024.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on September 2, 2026.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of May 27, 2026
Ownership
CMS lists this home under a new chain.
8 citations
Health inspection on May 22, 2026
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
58 of 387 Iowa homes (15%) got a citation at the actual harm level in 2026.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 5, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0550 2 times since 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 5, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0609 2 times since 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 5, 2026.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0725 2 times since 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 5, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 5, 2026.
Fine
May 22, 2026 (5 months ago)
CMS fine of $15,260 on May 22, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
1 citation
Health inspection on December 15, 2025
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 22, 2025.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
1 citation
Health inspection on October 8, 2025
CMS lists this as a complaint inspection.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 10, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health citation
CMS removed citation F0625 from the health inspection on August 11, 2024.
Health citation
CMS removed citation F0758 from the health inspection on August 11, 2024.
7 citations
Health inspection on June 26, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on July 11, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 11, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 11, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on July 11, 2025.
CMS has cited this home for F0644 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 11, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 11, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 11, 2025.
1 citation
Fire safety inspection on June 26, 2025
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 29, 2025.
CMS has cited this home for K0353 2 times since 2024.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
2 citations
Health inspection on October 22, 2024
CMS lists this as a complaint inspection.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on November 1, 2024.
CMS has cited this home for F0658 2 times since 2024.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on November 1, 2024.
10 citations
Health inspection on August 11, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 5, 2024.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on September 5, 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 5, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 5, 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 5, 2024.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on September 5, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 5, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 5, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 5, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 5, 2024.
9 citations
Fire safety inspection on August 11, 2024
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on September 13, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 12, 2024.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on September 5, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 5, 2024.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on August 28, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 27, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 28, 2024.
Citation K0522. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have an externally vented heating system.
CMS lists it as corrected on August 28, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on August 27, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
2 citations
Health inspection on May 15, 2024
CMS lists this as a complaint inspection.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on May 31, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 31, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- AMERICAN LUTHERAN CHURCH5% or greater direct ownership interest · 100% · since 02/14/2003
- AMERICAN LUTHERAN CHURCHOperational/managerial control · not applicable · since 02/14/2003
- THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOperational/managerial control · not applicable · since 11/20/2007
- NORBY, NICKLOSOperational/managerial control · not applicable · since 02/14/2020
- SHELL, STEPHENOperational/managerial control · not applicable · since 08/01/2025
Questions
When was Salem Lutheran Home last inspected?
CMS lists August 13, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Salem Lutheran Home have?
CMS lists 39 health citations since May 15, 2024. CMS also calls these deficiencies.
Has Salem Lutheran Home been fined?
CMS lists 1 fine in the past three years, $15,260 in total.
What is the CMS star rating of Salem Lutheran Home?
Its CMS overall star rating is 2 of 5.
Is Salem Lutheran Home a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.