Martin Luther Care Center

In the surveyor’s words

From the most serious findings on record at Martin Luther Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jun 12, 2025

  Based on observation, interview, and document review, the facility failed to ensure written Physician's Orders for Life Sustaining Treatment (i.e., POLST) were accurately entered, transcribed and reflected in the medical record in a timely manner to help guarantee correct resuscitation measures (i.e., DNR or CPR) would be performed in accordance with resident wishes for 2 of 2 residents (R50, R321) reviewed for advanced directives. These findings constituted an immediate jeopardy (IJ) situation for R50 who would have received cardiopulmonary resuscitation measures (CPR) against her declared wishes. […]

• Immediate jeopardy, isolatedF678Oct 24, 2024

  Based on interview and record review the facility failed to follow 1 of 3 residents (R1's) Physician Orders for Life-Sustaining Treatment (POLST) do not resuscitate, do not intubate, allow for natural death when R1 was found unconscious in his bed and registered nurse (RN)-A initiated CPR. This deficient practice had the potential to prolong R1's right for a natural death encumbered by potential complications of unnecessary life saving measures. The IJ began on [DATE] at 2:45 a.m. when RN-1 was found unresponsive in his room and RN-A initiated chest compressions. The IJ was identified on [DATE]. The Administrator and the Director of Nursing were notified on [DATE] at 5:00 p.m. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observation, interview and document review, the facility failed to ensure expired and visibly molding produce was disposed to prevent serving expired food. This had potential to affect all residents, visitors and staff who consumed food from the main kitchen. Findings include: During the initial kitchen tour with the dietary director (DD) on [DATE] at 12:10 p.m., the walk-in cooler was observed, which stored food served to all units of the facility and contained the following expired foods; an unopened bag of broccoli with a use-by date of [DATE], which was noticeably watery with brown spots, four unopened five-pound bags of brussels sprouts with a use-by date of [DATE], a cardboard box with approximately 25 cucumbers with noticeable denting open areas and white colored mold, a… […]

• No harm, potential for more than minimal, widespreadF880Apr 18, 2024

  Based on observation, interview and record review the facility failed to ensure appropriate infection control measures were implemented for direct resident care for 1 of 1 residents (R230) who was placed on enhanced barrier precautions. In addition, the facility failed to ensure clean personal and facility laundry was protected during transport and storage outside resident rooms. This had the potential to affect all 132 residents who utilized facility provided laundry services. […]

• No harm, potential for more than minimal, widespreadF812Mar 23, 2023

  Based on observation, interview, and document review, the facility failed to ensure 3 of 3 commercial food cooling devices (i.e., refrigerators, freezers) had ongoing monitoring of temperature and function to reduce the risk of potential foodborne illness; failed to ensure 1 of 2 commercial can openers was kept in a clean and sanitary manner; and failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk of cross-contamination. These findings had potential to affect all 123 residents, staff, and visitors, who consumed food prepared from the main production kitchen. […]