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Nursing HomeMedicaid Investigative

Salem Lutheran Home

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2027 College Avenue, Elk Horn, IA 5153164 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
5.0/5

based on 4 Google reviews

Salem Lutheran Home Nursing Home in Elk Horn, IA — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (9 vs median 5)
  • High staff turnover (65%)
  • High RN turnover (85%)

Bottom 25% in IA · $25,448 in fines

Source: Medicare data

What this means for your family

While the facility is praised for its physical environment and location, the lack of detailed reviews makes it difficult to verify the quality of daily care. Families should schedule an in-person tour to observe staff-resident interactions and ask specific questions about care protocols, as online feedback is currently insufficient to form a comprehensive opinion.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.54hrs
72%
Registered nurses for medical care
Total Nursing
3.56hrs
87%
All nurses + aides combined
Staff Turnover
69%
Lower is better (< 30% = good)
RN Turnover
73%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
2/ 5
Better Than Avg

9

measures

Worse Than Avg

5

measures

Mixed Results

2

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility29.1%
Worse than Avg
Here
29.1%
US
19.4%
IA
25.9%
Shelby
16.6%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.5%
Better than Avg
Here
99.5%
US
93.4%
IA
93.9%
Shelby
87.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.8%
Better than Avg
Here
3.8%
US
12.1%
IA
4.1%
Shelby
11.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility21.7%
Worse than Avg
Here
21.7%
US
15.3%
IA
17.5%
Shelby
17.7%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.6%
Worse than Avg
Here
19.6%
US
14.4%
IA
17.6%
Shelby
14.2%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility95.8%
Better than Avg
Here
95.8%
US
95.5%
IA
95.3%
Shelby
91.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility91.5%
Better than Avg
Here
91.5%
US
81.8%
IA
84.1%
Shelby
74.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
IA
2.0%
Shelby
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

9deficiencies
Above state avg (6.2)
12 complaint-triggered
$25,448 in fines

Families have filed complaints prompting inspections at Salem Lutheran Home, with 12 complaint-triggered deficiencies out of 55 total across recent surveys. The most recurring issues involve care planning and quality standards, infection control, and safety/emergency preparedness protocols. While all deficiencies show correction dates, the pattern of repeated complaints and violations across multiple care areas warrants careful evaluation during your visit.

Dec 15, 2025Complaint
1
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Oct 8, 2025Complaint
1
0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jun 26, 2025Routine
6
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jun 26, 2025Complaint
2
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Oct 22, 2024Complaint
2
0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0602Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Aug 11, 2024Routine
19
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0004Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0222Potential for harm · PatternCorrected

Egress Deficiencies

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.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0522Potential for harm · IsolatedCorrected

Services Deficiencies

Have an externally vented heating system.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

State Inspection History

State Inspections

Source: Iowa Dept. of Inspections, Appeals & Licensing

10total
22deficiencies
May 22, 2026Complaint
Clean

Fed violations: 8, State violations: 2

Jan 15, 2026Complaint
Clean

Fed violations: 0, State violations: 0

Dec 15, 2025Complaint
Clean

Fed violations: 1, State violations: 0

Dec 1, 2025Complaint
Clean

Fed violations: 0, State violations: 0

Oct 8, 2025Complaint
Clean

Fed violations: 1, State violations: 0

Jul 11, 2025Inspection
Clean

Fed violations: 0, State violations: 0

Jun 26, 2025Inspection
Clean

Fed violations: 7, State violations: 1

Nov 1, 2024Complaint
Clean

Fed violations: 0, State violations: 0

Ownership & Operations

Who Operates This Facility

Owner / Operator

Salem Lutheran Home

Organization Type

for profit

Chain Affiliation

Chain Name

Good Samaritan Society

Chain Size

92 facilities nationwide

Ownership & Management

Owners

American Lutheran Church

Owner · Organization

100%

Key personnel

Blakestad, AlanOfficer / DirectorGude, PaulOfficer / DirectorNielsen, PhilOfficer / DirectorSchechinger, TamiOfficer / DirectorAmerican Lutheran ChurchManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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