St John's Lutheran Home

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 21, 2022

  Based on interview and record review, the facility failed to protect residents from staff abuse resulting in a bruise for 1 (#71) and emotional distress for 4 (#s 9, 28, 69, and 71) of 4 sampled residents. Findings include: 1. Review of the Facility Reported incident on 5/8/22 at 5:15 p.m., showed, Staff was notified that [staff member N] was kicking [resident #71]. [Staff member N] was asked not to return to the facility as she was a per diem agency [staff member N job title]. Police notified and investigation opened into the event. Findings . It was noted that [resident #71] did have a bruise to his left medial calf. [staff member L] did witness [staff member N] kicking [resident #71] foot pedals and legs under the dining room table. […]

• Actual harm, isolatedF686Jul 21, 2022

  Based on observation, interview, and record review, the facility staff failed to prevent the development of pressure injuries resulting in pain for 1 (#48) and transfer to a higher level of care due to infection for 1 (#27); and failed to evaluate and document consistently the wound stage and characteristics for 1 (#48) of 2 sampled residents. These deficient practices had the potential to effect other residents who were at risk for altered skin integrity. Findings include: 1. During an interview on 7/20/22 at 2:16 p.m., with staff members I and J, staff member I stated resident #27 had a pressure wound located on her tailbone area. Staff member I stated she was not sure when the wound first occurred. […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2025

  Based on observation, interview, and record review, the facility failed to dispose of expired foods; failed to ensure dietary staff prepared and served food in a sanitary manner; and failed to properly test dish sanitization water used to sanitize dishes in the kitchen. This deficient practice had the potential to affect all residents served food in the LTC Cottages by increasing the risk of foodborne illnesses. Findings include: 1. During an observation and interview on 7/16/25 at 7:58 a.m., several items were observed to have expired and were still in use. Staff member E stated all items should be dated with an open date, and any expired items used past their use-by date should be discarded. […]

• No harm, potential for more than minimal, widespreadF880Jul 17, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene after assisting residents; failed to ensure staff used appropriate hand hygiene while preparing ready-to-eat foods; and failed to ensure enhanced barrier precautions were followed for 1 (#4) of 25 sampled residents. This deficient practice increased the spread of bacteria and increased the risk of infections to residents in the facility. Findings include:1. During an observation on 7/15/25 at 11:04 a.m., staff member G brought a resident, via wheelchair, placed her at a dining table after rubbing her back when speaking to her, went to the kitchen and brought a cup of coffee to another resident seated at a separate table. […]

• No harm, potential for more than minimal, widespreadF803Aug 15, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents were served meals to meet their nutritional needs, and staff serving meals failed to use the menu's and serve the planned meal, or offer an appropriate substitute, for the residents in the [NAME] Cottage. Findings include. During observations on 8/13/24 from 8:39 to 8:58 a.m., in the [NAME] cottage, staff member N did not review the residents diet orders or the menu prior to meal service. Staff member N did not use the required scoop size when serving the protein. Staff member N did not use a scoop when serving the bacon. Staff member N used her hand to scoop bacon out of the robo coupe. Five residents had orders for minced and moist diet. […]