St Luke's Elmore Long Term Care

In the surveyor’s words

From the most serious findings on record at St Luke's Elmore Long Term Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, staff interview, and the FDA Food Code, the facility failed to ensure food was stored, prepared, and served under sanitary conditions to prevent contamination and ensure food was safe and unadulterated. These failures had the potential to expose residents to foodborne illness. Findings include:Food Code 3-101.11 stated food should be safe, unadulterated, and honestly presented.1.On 1/20/26 at 9:19 AM, during a brief kitchen tour a container of soft strawberries with fuzzy white substances was observed in the front kitchen fridge where fresh produce and snacks were stored.On 1/20/26 at 9:20 AM, the Food Service Manager stated the facility goes by visibility and if the produce appears spoiled, they will dispose of it. […]

• No harm, potential for more than minimal, widespreadF842Jan 23, 2026

  Based on observation and staff interview, the facility failed to ensure resident records were safeguarded to prevent unauthorized access. This failure had the potential to allow misuse or disclosure of resident information. Findings include:On 01/20/26 at 9:40 AM, a medication cart was observed in the hallway in front of room [ROOM NUMBER]. The medication cart contained a laptop that was logged into the electronic medical record system, displaying access to multiple resident records. No staff member was present at the cart at the time of the observation.On 01/20/26 at 9:45 AM, the Interim Director of Nursing stated the expectation is that resident records are to remain secured to prevent unauthorized access.

• No harm, potential for more than minimal, patternF656Jul 23, 2021

  Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans included individualized, resident-centered interventions and goals related to oxygen therapy. This was true for 5 of 11 residents (#2, #4, #7, #9 and #12) whose care plans were reviewed. This failure placed residents at risk for negative outcomes if services were not provided, or provided incorrectly, due to lack of information on their care plans. […]

• No harm, potential for more than minimal, patternF887Jul 23, 2021

  Based on record review and staff interview, it was determined the facility failed to ensure there was documented evidence COVID-19 vaccines were offered to the staff, or documentation of staff decisions to accept or decline the vaccine and if declined, the reason they declined. This was true for 9 of 26 staff (RN #1, RN #4, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, the Health Unit Coordinator, and the Activity Coordinator) reviewed for COVID-19 vaccinations. This failure created the potential for staff to have increased risk of exposing undetected COVID-19 to residents, visitors, and other employees. […]

• No harm, potential for more than minimal, isolatedF554Jan 23, 2026

  Based on observations, record review, and staff interview, it was determined the facility failed to ensure a resident who was self-administering a medication was assessed to effectively do so. This was true for 1 of 1 resident (Resident #4), whose record was reviewed for self-administration of medications assessment. This failure placed Resident #4 at risk for adverse outcomes if she were to use the medication inappropriately. Findings include: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including leukemia and rheumatoid arthritis. On 1/22/26 at 8:34 AM, RN #1 was observed setting the single use vial of cyclosporine eye drops on Resident #4's bedside table and let her know she could use them whenever she wanted and to let him know later. […]