St John Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 24, 2021

  Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide adequate supervision and safety with smoking for 1 of 1 resident (R4) identified to have cigarette [CONDITION(S)] on clothing and wheelchair. This resulted in an immediate jeopardy (IJ) situation, substandard quality of care, for R4 who remained at risk for [CONDITION(S)] and serious injury with unsupervised smoking. The IJ began on 9/23/21, when it was identified R4 had sustained incidents of cigarette [CONDITION(S)] to his clothing and wheelchair from unsupervised smoking. On 9/23/21, at 1:52 p.m., the director of nursing (DON), administrator, and social worker (SW) were notified of the IJ for R4. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2026

  Based on observation, interview, and document review, the facility failed to ensure kitchen and walk-in cooler was clean and free of food-like debris. In addition, kitchen staff failed to consistently log dishwasher temps to ensure proper sanitation and failed to date meat when placed in the walk-in cooler to thaw. This had the potential to affect all 51 residents. Findings include: FOOD STORAGE/KITCHEN CLEANLINESSObservation on 6/1/26 at 10:55 a.m., in the kitchen identified:The stove-top had food crumbs and a dried liquid on and between the burners and the wall behind the stove had food debris splashed upon the wall. […]

• No harm, potential for more than minimal, widespreadF865Jun 3, 2026

  Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance Program Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 51 residents. Findings include: Review of the designated quarterly QAPI meetings from June 2025 through April 2026 identified facility departments were submitting data for review by the committee, but the minutes lacked evidence of measurable goals, discussion of the data submitted, and a plan of action for improvement. […]

• No harm, potential for more than minimal, widespreadF921May 14, 2025

  Based on observation, interview, and document review the facility failed to ensure the kitchen ceiling tiles were kept in a clean and sanitary manner and free of dust and debris. This had the potential to affect all 46 residents residing in the facility. Findings include: On 5/13/25 at 9:08 a.m., two ceiling tiles located approximately six feet from the steam table were observed with gray, fuzzy material hanging from them. Directly beneath these ceiling tiles were two metal meal carts. At the time of observation, cook (C)-A was interviewed and confirmed the presence of the gray fuzzy material on the ceiling tiles, acknowledging the condition was unclean and unacceptable. […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2024

  Based on observation, interview and document review, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 1 of 1 ice machines used for resident consumption. This had the potential to affect all 49 residents who resided in the facility. Findings include: During an observation on 4/16/24 at 10:39 a.m., noted a Manitowoc brand, counter-top style ice machine in the first floor resident ice machine. During an interview on 4/15/24 at 11:35 a.m., dietary supervisor (DS)-B stated dietary staff wiped down the outside of the ice machine located in the first-floor dining room but did not clean the inside. […]