Lutheran Community Home: Elopement Safety Gaps - IN
Nobody had written an order for the bracelet. Nobody had written an order to check whether it was working. Nobody had written an order to monitor the skin underneath it. And nobody had written a care plan explaining why the device was there or how staff should manage it.
The Assistant Director of Nursing described, during an interview on October 23, exactly what should have happened: once a resident is flagged as an elopement risk, his name and photo go into the computer, an order goes into the Electronic Medication Administration Record to monitor both the resident and the device, and a care plan gets written. "There should have been a Care Plan for the roam alert device, and an order added to his EMAR," the Assistant Director said.
The facility's own policies said the same thing. The Director of Nursing provided a policy on resident alarms stating that when alarms are in use, staff must verify they are working properly and watch for any adverse consequences. The Administrator provided a separate policy requiring a comprehensive, person-centered care plan for each resident.
None of that had been done for this resident in the six days since his return from the emergency room.
The inspection, a complaint investigation conducted October 23, cited the facility for the lapse. Inspectors rated the harm as minimal, affecting few residents. The bracelet remained on the man's ankle as the interview concluded.
What the record does not show is whether anyone checked, in those six days, whether the device was functioning, or whether the skin beneath it was holding up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lutheran Community Home from 2025-10-23 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
LUTHERAN COMMUNITY HOME in SEYMOUR, IN was cited for violations during a health inspection on October 23, 2025.
Nobody had written an order for the bracelet.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.