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Home / Iowa / Elk Horn

Salem Lutheran Home

2027 College Avenue, Elk Horn, IA 51531 · Shelby County · (712) 764-4201

64 certified beds, about 48 residents a day · For profit - Corporation · Medicare and Medicaid since 1990

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 165155 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on June 26, 2025, inspectors cited 7 health deficiencies (the Iowa average is 6.5, the national average 9.2).

Of 46 health citations since June 2023, 3 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $15,260 in the last three years; the largest was $15,260, and the latest is dated May 22, 2026.

Nurses and nurse aides worked 3.86 hours per resident per day, against 3.82 across Iowa and 3.86 nationally. Registered nurses accounted for 0.64 of those hours.

63.0% of nursing staff left within the year CMS measured (Iowa average 44.0%).

CMS links it to Good Samaritan Society, an affiliated group of 92 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
35D
7E
1F
Potential for minimal harm
0A
0B
0C
May 22, 2026Complaint inspection · 8 citations
  1. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, staff interviews, facility document review, and policy review the facility failed to ensure that a resident was free of significant medication errors for 1 of 4 residents reviewed (Resident #1). On 4/1/26, staff failed to remove the plastic backing off of a Fentanyl (a powerful synthetic opioid) patch for which resulted in Resident #1 not receiving any medication through the patch and experiencing more pain and required an increase in the use of liquid morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) medication until 4/3/26 when a new Fentanyl patch was replaced. The facility reported a census of 46 residents.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, policy and procedure review, resident and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed. (Resident #4). The facility identified a census of 46 residents.
  3. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to notify the physician of a pain patch that was not activated for 48 hours for 1 of 1 resident reviewed (Residents #1). The facility reported a census of 46 residents.
  4. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations of abuse involving mistreatment, neglect, and injuries of unknown source were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 2 of 3 resident reviewed. (Resident #2 and Resident #9). The facility reported a census of 46 residents.
  5. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to investigate injuries of unknown injury for 2 of 3 residents reviewed (Resident #2 and Resident #9). Resident #2 had a bruise on the right wrist and Resident #9 had a bruise underneath the left eye. The facility reported a census of 46 residents.
  6. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on resident and staff interviews, call light logs and the facility policy/procedure, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 4 residents reviewed (Resident #4, #5 and Resident #11). The facility identified a census of 46 residents.
  7. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, facility investigation review, staff interview and facility policy review, the facility failed to properly destroy Resident #1's narcotic (pain) medication per facility policy/procedure. The facility identified a census of 46 residents.
  8. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2026
    Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to maintain an accurate and complete resident clinical records for residents that had injuries of unknown origin for 2 of 3 residents reviewed (Resident #2 and Resident #9). The facility reported a census of 46 residents.
December 15, 2025Complaint inspection · 1 citation
  1. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 22, 2025
    Inspectors wroteBased on Electronic Health Record (EHR) review, resident interviews, family interviews, staff interviews and policy review the facility failed to provide dignity and respect when a nurse yelled at a resident about being outside of the facility and smoking on the sidewalk to 1 of 3 residents reviewed (Resident #1). The facility reported a census of 52 residents.
October 8, 2025Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 10, 2025
    Inspectors wroteBased on clinical record review, family interview, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living by not offering an opportunity to bathe for 2 of 3 residents reviewed (Resident #1,and #3). The facility reported a census of 56 residents.
June 26, 2025Standard inspection, Complaint inspection · 7 citations
  1. D
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wroteBased on clinical record review, family interview, staff interview, and policy review the facility failed to ensure 1 of 5 residents personal property was protected from loss or theft (Resident #14). The facility reported a census of 49 residents.
  2. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wroteBased on document review, staff interviews, and the facility policy review, the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment for 1 out of 5 staff reviewed. The facility reported a census of 49 residents.
  3. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wroteBased on electronic health record review, resident interview, personnel file review, facility policy review, and staff interview the facility failed to investigate and report alleged violations related to mistreatment to officials including the State Survey Agency in an appropriate time frame for 1 of 1 residents (Resident #37). The facility reported a census of 49 residents.
  4. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 2 residents with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 2 residents reviewed for PASRR requirements (Resident #16, #20). The facility reported a census of 49 residents.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wroteBased on record review, resident and staff interviews, the facility failed to provide quality of nursing care by leaving a resident on a bed pan for an extensive period of time without a call light and not documenting the event for 1 of 1 residents reviewed (Resident #37). The facility reported a census of 49 residents.
  6. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wrote2. Review of Resident #8's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The MDS further revealed Resident #8 utilizes oxygen therapy. Review of Resident #8's EHR page titled, Physician's orders revealed an order for oxygen 1 Liters Per Minute (LPM) per nasal cannula at night while sleeping. Interview 6/23/25 at 1:02 PM with Resident #8 revealed that she just puts the oxygen on, and is unsure how often the tubing is changed. Observation 6/23/25 at 1:02 PM oxygen tubing was noted to be dated 4/16/25, and humidification bottle was noted to be dated 4/23/25. Interview 6/24/25 at 10:37 AM with Staff A RN (Registered Nurse) revealed she works here every other weekend with an agency, and oxygen tubing is to be changed weekly on Wednesdays. Staff A then revealed that there is a book that shows oxygen tubing is to be changed weekly on Wednesday nights. [...]
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 11, 2025
    Inspectors wrote2. Review of Resident #9's MDS dated [DATE] revealed an admission date to the facility from a short-term general hospital stay 5/13/24. The MDS further revealed Resident #9 utilizes an indwelling catheter. Review of Resident #9's EHR page titled, Clinical Physician ' s Orders revealed an order for coudé (a type of urinary catheter with a curved or bent tip) catheter for infection control with a date of 4/22/25. Observation 6/25/25 at 11:06 AM Staff D Certified Nursing Assistant (CNA) brought Resident #9 into the bedroom to empty Resident #9's catheter drainage bag. Staff D then donned a gown and gloves with no hand hygiene. Staff D then obtained a urine graduate and placed it on a barrier on the floor. Staff D then drained the drainage bag without cleaning the drainage port of the drainage bag. After the drainage bag was emptied Staff D cleansed the drainage port with an alcohol wipe. [...]
October 22, 2024Complaint inspection · 2 citations
  1. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 1, 2024
    Inspectors wroteBased on record review, facility investigative file, staff interviews, resident interviews and facility policy review the facility failed to ensure staff followed professional standards while administering medications for 4 of 4 residents reviewed (Resident #3, #4, #5, and #6). The facility reported a census of 45 residents.
  2. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 1, 2024
    Inspectors wroteBased on observations, record review, facility camera footage review, staff interviews, resident interviews and facility policy review the facility failed to ensure 1 of 3 residents (Resident #1) was free from financial exploitation. The facility reported a census of 45 residents.
August 11, 2024Standard inspection · 10 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to prevent cross-contamination while serving food. The facility reported a census of 49 residents.
  2. E
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observations, menu review, and staff interviews, the facility failed to properly prepare and serve the appropriate portions of pureed diets for 3 of 3 residents and minced and moist diets for 7 of 7 residents. The facility reported a census of 49.
  3. E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 49 residents.
  4. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during toileting and urinary catheter care for 2 of 2 residents (Resident #1, Resident #35) observed. The facility also failed to perform hand hygiene between feeding two (2) residents. The facility reported a total census of 49 residents.
  5. D
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on clinical record review, resident interview and facility policy review, the facility failed to complete a bed hold notice with the resident or resident's responsible person when residents transferred out of the facility for 1 of 2 residents reviewed (Residents #12). The facility reported a census of 49 residents.
  6. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident #20), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 49 residents.
  7. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to develop a resident-centered comprehensive care plan for 3 of 3 residents reviewed (Resident #5, #18, and #39). The facility reported a census of 49 residents.
  8. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on clinical record review, resident interview, policy review and staff interview the facility failed to revise and update a care plan to include current transfer needs for 3 out of 4 residents reviewed (Resident #24, Resident #42, and Resident #16). The facility reported a census of 49 residents. Findings Included: 1. The Minimum Data Set (MDS) assessment dated 611/24 for Resident #24 documented diagnoses of pain in the left knee, muscle weakness and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The Progress Notes for Resident #24 showed the following: a. On 8/6/24 at 3:08 PM Resident #24 returned back to the facility after a procedure. Resident #24 reported having pain down her left leg. b. On 8/7/24 at 6:47 PM Resident #24 required a total lift to transfer to the wheelchair. [...]
  9. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observations, clinical record review, and policy review the facility failed to ensure physician's orders were followed for 1 of 1 resident (Resident #46) reviewed. The facility identified a census of 49 residents.
  10. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic mediation use for 2 of 3 residents reviewed ( Resident #18 & #39). The facility reported a census of 49 residents.
May 15, 2024Complaint inspection · 2 citations
  1. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observations, electronic health record (EHR) review, document review, resident interviews, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 2 of 5 resident reviewed (Resident #9 and #10). The facility reported a census of 52 residents.
  2. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when completing blood sugar monitoring for 3 of 3 residents reviewed (Resident #4, #5, and #6). The facility reported a census of 52 residents.
June 6, 2023Standard inspection · 15 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate a change in condition for three of three residents reviewed (Residents #22, #25, and #42). Two of the residents had a sudden increase of pain (Residents #22 and #25). Resident #22 walked independently in the facility and experienced a bout of dizziness causing her to fall on 5/13/23. At the time of the fall, Resident #22 denied pain but started to report pain later that evening and requested pain medication. Resident #22 did not use any as needed medication until after her fall on 5/13/23. Resident #22 received no evaluation by a provider until 5/17/23. During the hospital stay, the staff determined Resident #22 had multiple compression fractures in her back. Resident #22 received treatment to one of the compression fractures involving an invasive procedure. [...]
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on interviews, emergency room, hospital and facility record review, the facility failed to provide adequate nursing supervision to prevent injuries for 3 of 4 residents reviewed (Residents #22, #25, and #33) for falls. In addition, the facility failed to complete neurological assessments for 1 of 4 residents (Resident #22) reviewed for falls. Despite the facility documenting that Resident #25 had difficulties with standing with her transfers using the mechanical standing lift, no one adjusted the transfer technique to ensure her safety with transfers. Due to the staff continuing to transfer Resident #25 with an unsafe technique, she fell out of the standing lift resulting in a compression fracture in her back. [...]
  3. E
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on review of the facility schedule and staff interviews, the facility failed to have a Registered Nurse (RN) on duty for 8 hours a day, 7 days per week. The facility reported a census of 49 residents.
  4. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on observations interviews and record review the facility failed to destroy and have an accurate account for discontinued narcotic medications for 2 of 2 residents reviewed (Residents #25 and #101). Resident #25 and Resident #101 had their narcotic medications discontinued but the pills remained in the medication storage room and the medication cart.
  5. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on observations, resident, and staff interviews the facility failed to serve hot food to residents in their rooms. The facility reported a census of 48 residents.
  6. D
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure resident's current code status was available for 1 out of 16 residents reviewed (Resident #201).
  7. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to notify the family for a significant change in condition for 1 of 16 residents reviewed (Residents #42) for pressure ulcers.
  8. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on observation, interviews, and chart review the facility failed to prevent the mishandling of a resident's narcotic medications for 1 of 4 residents reviewed (Resident #38).
  9. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate the sudden increase of pain for a resident who received scheduled pain medication for chronic pain who used a standing lift for transfers for one of one resident reveiwed (Resident #25). Despite reports that Resident #25 had difficulty standing with the standing mechanical lift, the facility did not investigate the concern. Without investigation of the concern, the staff continued to transfer Resident #25 with the standing mechanical lift. After a change in condition, the facility sent Resident #25 to the hospital who discovered a compression fracture.
  10. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on facility record review, facility policy review, resident, and staff interviews the facility failed to revise and update the Care Plan to address the increased needs of Activities of Daily Living (ADLs) for 1 of 1 residents reviewed (Resident #25).
  11. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 16 residents reviewed (Residents #45 and #33). The facility failed to obtain weights as ordered by the physician for Resident #45. In addition, the facility failed to document the administration of medications, blood sugars, and bed time (HS) snacks for a diabetic resident.
  12. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on observations, staff interviews, facility record review, and policy review the facility failed to ensure residents received the necessary interventions and care consistent with professional standards of practice to prevent deterioration of a wound, heal a stage 2 pressure ulcer, and prevent the development of new ulcers for 2 of 2 residents reviewed (Residents #251 and #24). The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). [...]
  13. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to complete dialysis assessments before and after outpatient hemodialysis treatments for 1 of 1 resident reviewed (Resident #42).
  14. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on clinical record review and staff interviews, the facility failed to have a complete and accurate medical record for 2 of 16 residents reviewed (Residents #45 and #251). After Resident #45 fell, their clinical record lacked a progress note related to the incident. During incontinence cares, the facility staff observed open areas to Resident #251. After reporting the concerns to the nurse, the clinical record lacked documentation of his open areas.
  15. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 26, 2023
    Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene and gloving practices consistent with accepted standards of practice for 1 of 2 residents reviewed (Resident #45) while providing catheter care.

Fire safety inspections

17 fire safety citations on file: 1 on June 26, 2025, 9 on August 11, 2024, 7 on June 6, 2023.

Every fire safety citation17 citations
  1. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 26, 2025 · Corrected (the home has a date of correction)
  2. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · August 11, 2024 · Corrected (the home has a date of correction)
  3. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · August 11, 2024 · Corrected (the home has a date of correction)
  4. F
    Provide a written emergency evacuation plan.
    K 711 · August 11, 2024 · Corrected (the home has a date of correction)
  5. F
    Have simulated fire drills held at unexpected times.
    K 712 · August 11, 2024 · Corrected (the home has a date of correction)
  6. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · August 11, 2024 · Corrected (the home has a date of correction)
  7. E
    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.
    K 222 · August 11, 2024 · Corrected (the home has a date of correction)
  8. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 11, 2024 · Corrected (the home has a date of correction)
  9. D
    Have an externally vented heating system.
    K 522 · August 11, 2024 · Corrected (the home has a date of correction)
  10. D
    Have proper medical gas storage and administration areas.
    K 923 · August 11, 2024 · Corrected (the home has a date of correction)
  11. F
    Conduct testing and exercise requirements.
    E 39 · June 6, 2023 · Corrected (the home has a date of correction)
  12. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 6, 2023 · Corrected (the home has a date of correction)
  13. F
    Have simulated fire drills held at unexpected times.
    K 712 · June 6, 2023 · Corrected (the home has a date of correction)
  14. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · June 6, 2023 · Corrected (the home has a date of correction)
  15. E
    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
    K 362 · June 6, 2023 · Corrected (the home has a date of correction)
  16. E
    Ensure proper usage of power strips and extension cords.
    K 920 · June 6, 2023 · Corrected (the home has a date of correction)
  17. D
    Have properly installed electrical wiring and gas equipment.
    K 511 · June 6, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
May 22, 2026Fine $15,260

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIowaUnited States
All nursing staff (RN, LPN and aides)3.863.823.86
Registered nurses0.640.740.69
All nursing staff on weekends3.173.373.42
Nurse aides2.58
Licensed practical nurses0.64
Nursing staff turnover (share who left in a year)63.0%44.0%45.8%
Registered nurse turnover80.0%42.1%42.9%
Administrators who leftnot reported

CMS expects 2.89 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.14 on weekdays and 3.17 on weekends, 23% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.29 in April to June 2025 to 3.86 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.860.644.143.17 8.0%1 of 9048
Oct to Dec 20253.560.543.902.70 13.6%1 of 9255
Jul to Sep 20252.950.583.182.34 28.6%2 of 9257
Apr to Jun 20253.290.713.602.53 29.5%2 of 9150
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Iowa, Jan to Mar 20263.800.713.983.364.7%0.3% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Iowa

JobMedianMiddle halfEmployed
Iowa, all employers
CNAs (nursing assistants)$18.92$17.96 to $21.9522,670
LPNs and LVNs$30.11$27.12 to $34.065,510
Registered nurses$37.80$32.83 to $41.3234,420
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Salem Lutheran Home. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
Usual shift
Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIowaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
18.317.113.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.01.50.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.12.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
6.33.83.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.02.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
21.616.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
1.74.24.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
18.119.415.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
27.720.923.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
11.613.212.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.91.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
3.92.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Salem Lutheran Home's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (38.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

38.5% this home

No different from the national rate

US median of homes 51.5% · Iowa: 28 better, 21 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 41 eligible stays.

Potentially preventable readmissions

10.2% this home

No different from the national rate

US median of homes 10.7% · Iowa: 1 better, 1 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 63 eligible stays.

Infections that led to a hospital stay

9.2% this home

No different from the national rate

US median of homes 7.1% · Iowa: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 31 eligible stays.

Self-care and mobility at discharge

45.2% this home

Median of homes: Iowa56.7% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 31 residents counted.

Falls with major injury

5.6% this home

Median of homes: Iowa0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 36 residents counted.

New or worsened pressure ulcers

0.0% this home

Median of homes: Iowa1.8% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 36 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Iowa100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: AMERICAN LUTHERAN CHURCH. CMS links this home to Good Samaritan Society, a group of 92 nursing homes averaging 3.1 stars overall.

NameRoleTypeShareSince
American Lutheran Church5% or greater direct ownership interestOrganization100%02/14/2003
Blakestad, AlanCorporate officerIndividual03/01/2020
Gude, PaulCorporate officerIndividual03/01/2021
Nielsen, PhilCorporate officerIndividual03/06/2016
Schechinger, TamiCorporate officerIndividual03/01/2021
American Lutheran ChurchOperational/managerial controlOrganization02/14/2003
The Evangelical Lutheran Good Samaritan SocietyOperational/managerial controlOrganization11/20/2007
Norby, NicklosOperational/managerial controlIndividual02/14/2020
Shell, StephenOperational/managerial controlIndividual08/01/2025
American Lutheran ChurchAdp of the SNFOrganization02/14/2003
Shell, StephenAdp of the SNFIndividual08/01/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 11 problems in this area, most recently on May 22, 2026: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on May 22, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 7 problems in this area, most recently on May 22, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
  4. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on October 8, 2025: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.17 hours per resident per day, below the Iowa average of 3.37.

Other nursing homes nearby

Iowa contacts for a concern about a nursing home

These are the official offices in Iowa. NursingHomeClear cannot take or act on complaints.

Common questions

What is Salem Lutheran Home's Medicare star rating?
CMS rates Salem Lutheran Home 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Salem Lutheran Home get at its last inspection?
7 health deficiencies at the standard inspection on June 26, 2025. The Iowa average is 6.5.
Has Salem Lutheran Home been fined?
Yes. CMS lists 1 fine totaling $15,260 in the last three years.
Does Salem Lutheran Home accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Salem Lutheran Home?
CMS lists 11 owners and managers, and links the home to Good Samaritan Society. Legal business name: AMERICAN LUTHERAN CHURCH.

Sources

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