St Luke Lutheran Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 4, 2025

  Based on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure residents needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #54). This failure resulted in the resident falling out of the mechanical lift during a transfer and obtaining injuries and therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to prevent further falls by following the care plan and implemented interventions for 1 of 1 residents reviewed (Resident #70). […]

• Immediate jeopardy, isolatedF689Aug 22, 2024

  Based on observation, interviews, video and record review, the facility failed to account for the whereabouts of 1 of 1 resident reviewed (Resident #16), and failed to ensure that the door alarms were activated. The facility failed to transfer correctly 1 of 1 resident reviewed for a transfer with a sit to stand lift, (Resident #23). On the evening of 5/7/24, Resident #16 used the handicap button, that did not trigger an alarm, to exit through the front door at 7:20 PM. A staff member from the assisted living facility returned him to the nursing home at 10:10 PM. Nursing home staff were unaware that he had been gone for over 2 hours and that he had fallen during his time outside. Staff later found that the alarm to the front door had been turned off earlier that evening. […]

• No harm, potential for more than minimal, patternF550Sep 4, 2025

  Based on observation, resident interviews, and staff interviews the facility failed to respect each resident's dignity throughout all care and services provided to 6 out of 22 residents reviewed (Resident #5, #44, #54, and #80 ). The facility reported a census of 68 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of dementia, vision impairment and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF943Sep 4, 2025

  Based on personnel file review, facility policy review and staff interview the facility failed to meet requirements for Dependent Adult Abuse Mandatory Reporter Training for 1 of 5 employees reviewed (Staff H). The facility identified a census of 68 residents.Findings include:Review of Staff H, Certified Nursing Assistant (CNA) personal file revealed Dependent Adult Abuse Mandatory Reporter Training certificate dated [DATE]/22. The file also revealed Staff H repeated the training on [DATE]. […]

• No harm, potential for more than minimal, patternF578Aug 22, 2024

  Based on record review, interview and policy review the facility failed to obtain complete resident records. A facility form titled: Authorization for Withholding CPR (Cardiopulmonary Resuscitation) did not include a date, or physician signature and/or a witness signature for 4 of 27 reviewed, (Residents #3, #23, #2 and #121) . The facility reported a census of 67 residents. Findings include: 1. According to the Face Sheet for Resident #3, he was admitted to the facility on [DATE] with a Do Not Resuscitate (DNR). Do not attempt to restore heartbeat and breathing following a cardio pulmonary arrest. A form titled; Authorization for Withholding CPR signed by the resident, included a handwritten note, I want CPR and the writing was scribbled out. […]