St Luke Community Nursing Home

In the surveyor’s words

From the most serious findings on record at St Luke Community Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to evaluate and implement individualized and affective fall prevention care plan interventions, after a resident's fall with a major injury which resulted in blindness in one eye, and the resident to continued to fall, and had three more injuries, for 1 (#11); failed to assess, revise, and implement fall interventions, to prevent falls, for 2 (#s 14 and 25); and failed to ensure staff were trained in fall prevention and reporting, resulting in a major injury, for 1 (#39) of 8 sampled residents. Findings include: On 3/15/23 at 3:04 p.m., the St. […]

• Actual harm, isolatedF689Mar 27, 2025

  Based on observations, interviews, and record review, the facility failed to ensure staff utilized safety straps for sit-to-stand lifts, resulting in a fall with major injury, for 1 (#11); and placing residents requiring the use of the sit-to-stand lift at risk of falls, for 3 (#s 9, 20, and 23) of 4 sampled residents; and failed to ensure a resident was sufficiently assessed on an ongoing basis and monitored for the use of a Broda chair related to her fall risk and prevention, which may have led to a further decline in mobility, for 1 (#10) of 19 sampled residents. Findings include: 1. During an interview on 3/25/25 at 4:04 p.m., staff member R stated resident #11 slid out of the sit-to-stand mechanical lift a few months ago. […]

• Actual harm, isolatedF600Jan 20, 2022

  Based on observation, interview, and record review, the facility failed to prevent and protect 3 (#s 4, 16, and 92) of 4 sampled residents, and put other residents at risk, from repeated physical and potential psychosocial abuse by a resident (#31) over an extended period of time. Findings Include: During an observation and interview, on [DATE] at 2:42 p.m., resident #31 was observed sitting in a recliner. Resident #31 did not respond to questions when asked. Review of resident #31's current care plan, initiated on [DATE], showed he had a BIMS score of 99 (severe cognitive impairment), and he could not verbally communicate. […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe labeling of food storage in accordance with professional standards for food service safety, placing residents at risk for consumption of expired or contaminated food and risk for food-borne illness; and failed to develop and implement policy and procedures regarding food storage and labeling. These deficient practices affected all residents receiving food services from the facility. Findings include: During an observation on [DATE] at 11:40 a.m., the following had incomplete or missing labels, with dates, in the kitchen and dining areas: - Blueberries (opened) in refrigerator, dated ,d+[DATE], no year noted; - Pickled relish (opened) in refrigerator dated ,d+[DATE], no year noted; - Pepperoni (opened) in… […]

• No harm, potential for more than minimal, widespreadF867Mar 27, 2025

  Based on interview and record review, the facility failed to maintain documentation of its ongoing QAPI program efforts which demonstrated how the facility determined contributing causes of problems to determine the root-cause of identified issues; failed to establish corrective action plans which included interventions to correct the problem to establish measurable outcomes for established goals; and failed to establish measurable goals in order to determine a process on how to monitor projects to ensure expected results of the established goals. […]