St Luke Lutheran Community-Portage Lakes

In the surveyor’s words

From the most serious findings on record at St Luke Lutheran Community-Portage Lakes, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 30, 2024

  Based on medical record review, interviews, review of facility policy, and review of a facility self-reported incident (SRI) investigation, the facility failed to ensure Resident #7 was free from staff to resident physical abuse. This affected one resident (#7) of three residents reviewed for abuse. The facility census was 38. Actual harm occurred on 09/09/24 when Resident #7 was physically abused by a State tested Nursing Assistant (STNA) during care resulting in large areas of bruising to both of the resident's arms. Bruising to the left upper arm measured 4.5 centimeters (cm) in length by 3.0 cm width and was described as purple to dark red in color. Bruising to the right upper arm measured 15.0 cm in length by 6.0 cm with and was described as deep purple and dark red with intact skin. […]

• No harm, potential for more than minimal, widespreadF725Aug 13, 2026

  Based on observations of staff, staff interview, review of the Payroll Based Journal (PBJ) report, review of staff schedules for the residential care facility (RCF) and skilled nursing facility (SNF), the facility failed to have a distinct dedicated staff to provide care and services to the SNF residents and failed to ensure they reported accurate information for PBJ report. This had the potential to affect all 49 residents residing in the SNF. The facility census was 49. Findings include:1. Review of the schedules for SNF and RCF, also commonly referred to as Assisted Living (AL), revealed they were written on the same page. It had four to five assignments with specified units or rooms on SNF and then an AL assignment.Interview on 08/10/26 at 1:58 P.M. […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2026

  Based on observation, staff interviews, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect 93 out of 94 residents residing in the facility. Resident #10 was identified by the facility as eating nothing by mouth. The facility census was 94.Findings include:A tour of the kitchen on 08/10/26 at 8:08 A.M. with Dietary Aide (DA) #402 revealed near the tray line was a reach-in refrigerator that had a torn gasket with mold on the gasket and food residue on the bottom. There was a fan running in the kitchen that had grease and dust on the blades. The reach-in freezer had grease on the front of the freezer door and on the handle, and dust over the vents to the compressor. […]

• No harm, potential for more than minimal, widespreadF851Aug 13, 2026

  Review of the Payroll Based Journal (PBJ) report revealed that the facility failed to accurately report the required staffing information for PBJ report. This had the potential to affect all 49 residents. The facility census was 49. Findings include:Review of the PBJ report revealed one-star staffing for Quarter 3 2026.Interview on 08/10/26 at 9:00 A.M. with Administrator revealed the facility discovered they were not submitting Administrator hours for the PBJ which she stated was the cause of the one-star staff rating.Review of samples of PBJ reporting and interview on 08/12/26 at 3:40 P.M. with Director of Nursing (DON) revealed they did not report Administrator hours 11/30/25 through 12/06/25 and 08/16/26 through 08/22/26. […]

• No harm, potential for more than minimal, widespreadF921Aug 13, 2026

  Based on observation and staff interviews the facility failed to maintain a clean, sanitary and safe environment. The facility also failed to ensure there was enough linens to care for residents. This had the potential to affect all 49 residents residing in the facility. The facility census 49.Findings include:1. Observation on 08/11/26 at 5:45 A.M. revealed that the front door of the facility was opened wide. Activities Director (AD) #700 verified that the door was wide open at 5:50 A.M.Interview on 08/11/26 at 5:47 A.M. with Director of Nursing (DON) revealed that the front door of the facility should have been closed and locked. The DON had a head count of residents, and all residents were accounted for that resided in the facility.2. Observation on 08/11/26 at 5:55 A.M. […]