Inspection Reports for
Lutheran Village at Wolf Creek
2015 PERRYSBURG-HOLLAND ROAD, HOLLAND, OH, 43528
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
146% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
72% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 57
Deficiencies: 9
Date: Sep 8, 2025
Visit Reason
Routine inspection of Lutheran Village at Wolfcreek nursing home to assess compliance with healthcare regulations including resident rights, care quality, medication administration, infection control, and safety.
Findings
The facility was found to have multiple deficiencies including failure to document resident code status consistently, inadequate communication support for non-English speaking residents, insufficient oral hygiene care, improper pressure ulcer care, unsafe fall interventions, improper oxygen therapy administration, medication errors, expired medications, and lapses in infection control practices.
Deficiencies (9)
F 0578: The facility failed to ensure resident code status was documented across all medical records for two residents. Code status orders were missing or delayed in the electronic health record.
F 0676: The facility failed to provide consistent communication means for a non-English speaking resident, resulting in inability to communicate care needs when family was absent.
F 0677: The facility failed to provide adequate and timely oral hygiene care to a resident dependent on staff, with documentation showing missed oral care on multiple days.
F 0686: The facility failed to ensure pressure ulcer prevention interventions were applied as ordered, including inconsistent use of heel protector boots for a resident with stage four pressure ulcers.
F 0689: The facility failed to implement ordered fall interventions, including use of shorter oxygen tubing, contributing to a resident fall.
F 0695: The facility failed to ensure oxygen tubing was changed and labeled as required, and oxygen was administered at the ordered rate for four residents receiving oxygen therapy.
F 0760: The facility failed to ensure medications were administered per physician's order, including withholding midodrine without physician parameters, resulting in medication errors.
F 0761: The facility failed to ensure medications and biologicals were properly dated and discarded after expiration, including expired Geri-Lanta and undated Tuberculin PPD.
F 0880: The facility failed to ensure staff wore appropriate personal protective equipment, performed hand hygiene, sanitized medical equipment between residents, and disinfected insulin pens prior to use, risking infection transmission.
Report Facts
Residents affected: 2
Facility census: 57
Medication holds: 6
Oxygen tubing change frequency: 30
Oxygen tubing length: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #672 | Licensed Practical Nurse | Named in medication administration error for Resident #41 and infection control lapses |
| RN #682 | Registered Nurse | Named in insulin pen sanitation deficiency and medication administration |
| LPN #616 | Licensed Practical Nurse | Named in oxygen tubing labeling and cleaning deficiencies |
| CNA #705 | Certified Nurse Aide | Named in oral hygiene care deficiency for Resident #6 |
| CNA #657 | Certified Nurse Aide | Named in pressure ulcer care deficiency for Resident #7 |
| CNA #709 | Certified Nurse Aide | Named in failure to use PPE during care for Resident #19 |
| RN #708 | Registered Nurse | Named in failure to perform hand hygiene and gown use during gastrostomy care |
| LPN #610 | Licensed Practical Nurse | Named in oxygen tubing labeling and fall intervention deficiencies |
| LPN #710 | Licensed Practical Nurse | Named in pressure ulcer care observation |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration and infection control |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 4
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration, medication storage, and infection control practices at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00141941.
Findings
The facility failed to notify the physician when medications were held or not administered as ordered, failed to securely store medications, and failed to ensure proper hand hygiene during meal tray service. These issues affected multiple residents and represented non-compliance with facility policies and regulatory requirements.
Deficiencies (4)
F 0580: The facility failed to notify the physician when medications were held or not administered per physician's orders for Resident #43. Documentation and physician notification were lacking for medications held in February, March, and April 2023.
F 0755: The facility failed to administer medications per physician's orders for Resident #43, holding hydralazine and lisinopril without physician notification and not following medication administration policy.
F 0761: The facility failed to ensure medications were securely stored. Resident #20 had unsecured zinc oxide and muscle rub cream in their room, which were not ordered and should have been locked.
F 0880: The facility failed to ensure hand hygiene was performed after providing resident care during meal tray service. STNA #725 wore the same gloves between residents and did not perform hand hygiene, risking cross-contamination.
Report Facts
Facility census: 55
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents observed: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Verified medications were held without physician notification and policy was not followed | |
| Licensed Practical Nurse (LPN) #659 | Verified unsecured medications in Resident #20's room and stated they should have been locked | |
| State Tested Nurse Aide (STNA) #725 | Observed failing to perform hand hygiene between residents during meal tray service |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 14
Date: Apr 13, 2023
Visit Reason
The inspection was conducted based on complaints and concerns related to resident dignity, medication administration, care assistance, medication errors, medication storage, infection control, and other regulatory compliance issues at the nursing home.
Complaint Details
The inspection was complaint-driven, investigating multiple concerns including dignity, medication errors, care assistance, medication storage, infection control, and documentation issues. The complaint number is OH00141941.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to provide adequate assistance with activities of daily living, failure to notify physicians of medication holds, failure to accommodate resident needs, failure to administer medications as ordered, failure to ensure appropriate use of psychotropic medications, failure to maintain proper medication storage, failure to maintain safe food storage and sanitation, failure to document vaccinations properly, and failure to perform hand hygiene during meal service.
Deficiencies (14)
F 0550: The facility failed to ensure residents were treated with dignity and respect, affecting two residents reviewed for dignity.
F 0558: The facility failed to ensure a resident was evaluated for safe use of a motorized wheelchair and provided a foot pedal for the manual wheelchair.
F 0580: The facility failed to notify the physician when medications were not administered per physician's orders for one resident.
F 0677: The facility failed to ensure residents dependent on staff for activities of daily living received required assistance, including toileting and hygiene care.
F 0679: The facility failed to ensure activities of interest were provided to residents who stayed in their rooms.
F 0684: The facility failed to provide adequate care and treatment for a resident experiencing edema, including failure to apply compression stockings as ordered.
F 0690: The facility failed to ensure residents received timely incontinence care, resulting in a resident remaining in a saturated brief for hours.
F 0692: The facility failed to ensure a resident's physician ordered therapeutic diet was provided as ordered, serving prohibited foods.
F 0755: The facility failed to administer medications per physician's orders, holding medications without physician notification.
F 0760: The facility failed to prime insulin pens with 2 units of insulin prior to administration as required by manufacturer and facility policy.
F 0761: The facility failed to ensure medications were securely stored; unsecured zinc oxide and muscle rub cream were found in a resident's room.
F 0812: The facility failed to ensure foods were stored safely and the dishwashing machine sanitizer level was inadequate for effective disinfection.
F 0842: The facility failed to document resident vaccination records and screenings in the medical record as required by policy.
F 0880: The facility failed to ensure hand hygiene was performed after providing resident care during meal tray service.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 52
Residents affected: 4
Residents observed: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #659 | Licensed Practical Nurse | Named in dignity, ADL assistance, medication notification, and incontinence care findings |
| STNA #615 | State Tested Nurse Aide | Named in dignity and incontinence care findings |
| DOR #720 | Director of Rehabilitation | Named in wheelchair accommodation findings |
| Interim Director of Nursing (DON) | Named in medication administration and psychotropic medication findings | |
| RN #602 | Registered Nurse | Named in insulin administration findings |
| STNA #725 | State Tested Nurse Aide | Named in infection control hand hygiene findings |
| Dietary Staff (DS) #655 | Dietary Staff | Named in food storage and sanitation findings |
| Dietary Manager (DM) #606 | Dietary Manager | Named in food storage and sanitation findings |
| Activities Assistant (AA) #699 | Activities Assistant | Named in activities provision findings |
| LPN #631 | Licensed Practical Nurse | Named in incontinence care and psychotropic medication findings |
| STNA #632 | State Tested Nurse Aide | Named in activities, psychotropic medication, edema care, and incontinence care findings |
| STNA #671 | State Tested Nurse Aide | Named in incontinence care findings |
| STNA #730 | State Tested Nurse Aide | Named in diet provision findings |
| Dietary Aide (DA) #641 | Dietary Aide | Named in diet provision findings |
| Interim Director of Nursing (IDON) #613 | Named in psychotropic medication findings | |
| Registered Dietitian (RD) #710 | Registered Dietitian | Named in diet provision findings |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: Mar 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide residents with bathing assistance and timely medication administration.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00140803.
Findings
The facility failed to provide scheduled bathing assistance to residents #14 and #50 and failed to order and administer medications timely for these residents. These deficiencies represent non-compliance under Complaint Number OH00140803.
Deficiencies (2)
F 0677: The facility failed to provide bathing assistance as scheduled to residents #14 and #50, resulting in missed showers on multiple dates.
F 0755: The facility failed to order medications timely and ensure residents took medications under supervision, affecting residents #14 and #50.
Report Facts
Residents affected: 2
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #321 | Licensed Practical Nurse | Verified medication administration issues and lack of active medication order for Resident #50 |
| Director of Nursing | Verified missed showers for Residents #14 and #50 |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 5
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, rights, and facility operations at Lutheran Village at Wolfcreek.
Findings
The facility was found to have multiple deficiencies including failure to provide appropriately assessed wheelchairs, failure to respect residents' choice of rising time, failure to apply ordered splints for contractures, failure to implement nutrition recommendations following significant weight loss, and failure to ensure fluid restrictions were in place and monitored for dialysis patients.
Deficiencies (5)
F 0558: The facility failed to ensure residents were equipped with appropriately assessed wheelchairs. Resident #44's wheelchair was not an appropriate fit and the resident removed the seat cushion to propel herself.
F 0561: The facility failed to ensure residents who required staff assistance with transfer had their choice of rising time respected. Residents #92 and #71 were not assisted to get up when they wanted despite using call lights.
F 0688: The facility failed to ensure a resident with contractures had a splint applied as ordered. Resident #64 did not have the prescribed left resting hand splint in place.
F 0692: The facility failed to implement nutrition recommendations following significant weight loss. Resident #17 experienced an 11 percent weight loss in one month without a dietary consult ordered.
F 0698: The facility failed to ensure fluid restrictions were in place and monitored for a resident receiving dialysis. Resident #3's fluid intake was not properly tracked or restricted as ordered.
Report Facts
Facility census: 107
Residents reviewed for assistive devices: 26
Residents reviewed for choices: 3
Residents reviewed for nutrition: 4
Residents identified with contractures: 2
Residents identified with dialysis orders: 3
Weight loss percentage: 11
Weight on 09/12/19: 134
Weight on 10/04/19: 119
Fluid restriction: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #350 | Registered Nurse | Verified residents were not assisted to get up when they wanted and communicated with STNA about delays |
| STNA #280 | State Tested Nursing Assistant | Reported on residents' preferences and care assistance needs |
| STNA #290 | State Tested Nursing Assistant | Unaware of fluid restrictions for Resident #3 and responsible for fluid intake documentation |
| LPN #275 | Licensed Practical Nurse | Discussed Resident #3's fluid restriction and documentation responsibilities |
| Director of Nursing | Director of Nursing | Verified wheelchair fit issue and lack of assessment documentation; confirmed no dietary consult order for Resident #17 |
| OT #300 | Occupational Therapist | Verified residents' status and assisted Resident #71 with getting dressed and out of bed |
| OTA #310 | Occupational Therapy Assistant | Reported Resident #64 was discharged from OT services and provided discharge instructions |
| DT #250 | Dietary Technician | Reported no dietary consult order was placed for Resident #17 |
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