Saint Luke Lutheran Home

In the surveyor’s words

From the most serious findings on record at Saint Luke Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF744Aug 4, 2025

  Based on observation of facility recorded video footage with sound, observation of police officer body camera footage, medical record review, facility incident review, review of a self-reported incident, interview, dementia training curriculum review, facility assessment review and policy review the facility failed to ensure Resident #145, who was cognitively impaired and had a diagnosis of dementia, was provided adequate, necessary kind, appropriate and dignified dementia care to meet his total care needs. This resulted in immediate jeopardy and the potential for serious harm and injury on 07/06/25 at 5:46 A.M. when the resident began to wander throughout the facility secured dementia unit. […]

• Actual harm, isolatedF686Aug 4, 2025

  Based on observation, record review, policy review, and interviews, the facility failed to implement a comprehensive and resident centered plan to prevent and/or treat the development of pressure ulcers. Actual harm occurred beginning on 06/08/25 when Resident #95, who was at high risk for pressure ulcer development and dependent on staff for activities of daily living, developed an avoidable Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose [fat] is not visible, and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) to the left buttock. […]

• Actual harm, isolatedF686Jan 30, 2023

  Based on observation, review of the medical record, and interview, the facility failed to timely identify areas of new skin impairment for Resident #39. This affected one resident (Resident #39) of one reviewed for pressure ulcers. Actual harm occurred on 01/03/23 when Resident #39, who was cognitively impaired, at high risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) with a necrotic area to the left heel. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF730Mar 10, 2026

  Based on record review, and staff interview the facility failed to ensure annual evaluations was completed. This had the potential to affect all 121 residents. The facility census was 121. Findings include: Review of personal file for Certified Nursing Assistant (CNA) #718 revealed the facility had not completed an annual evaluation for CNA #718 since 04/21/21.Interview on 03/09/26 at 9:48 A.M. Human Resources Manager #995 verified the facility has not completed an annual evaluation on CNA #718 since 04/21/21.

• No harm, potential for more than minimal, widespreadF812Mar 10, 2026

  Based on observation, interview, and facility policy, the facility failed to maintain a sanitary kitchen This had the potential to affect all residents receiving meals from the kitchen. The facility indicated three (Residents #1, #63 and #136) do not receive meals from the kitchen as they receive nothing by mouth. The facility also failed to ensure resident room and unit refrigerators were monitored and maintained in a safe manner. This affected five (Residents #25, #85, #100, #101, and #110) and had the potential to affect 25 (Residents #6, #16, #22, #25, #26, #30, #34, #37, #38, #41, #43, #58, #74, #75, #82, #85, #97, #100, #101, #102, #104, #109, #110, #118, and #123) residents the facility indicated had room refrigerators. […]