St Luke's Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at St Luke's Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF804May 9, 2025

  Based on observation, interview, and record review, facility staff failed to ensure meals were served at a palatable temperature when staff failed to verify temperature of food to ensure proper holding temperature prior to starting meal service resulting in cold food not held at 41 degrees Fahrenheit (F) or lower. The facility had a census of 64. Review of the United States Department of Agriculture (USDA) website, food safety basics section titled, Danger Zone (40 degrees F to 140 degrees F), revised 06/28/17, showed the following information: -Cold food is to be kept at 40 degrees Fahrenheit or lower and placed in containers on ice; -Bacteria grows most rapidly in temperature ranges between 40 degrees F and 140 degrees F. […]

• No harm, potential for more than minimal, widespreadF868May 9, 2025

  Based on record review and interviews the facility failed to maintain quarterly Quality Assessment Committee (QAA) meetings with the required members when the Medical Director did not attend the QAA meetings. The facility census was 64. Review of the facility's Quality Assurance Committee policy, dated 06/11/07, showed the following: -Purpose to set forth guidelines for the formation and maintenance of a Quality Assurance Committee. -The Quality Assurance Committee will audit criteria in each department that are set by the committee which review work processes and procedures. […]

• No harm, potential for more than minimal, patternF576May 9, 2025

  Based on interview and record review, the facility failed ensure each resident's right to receive mail correspondence timely was honored when staff failed to provide mail delivered on Saturdays to residents timely. The facility census was 64. Review of the facility did not provide a policy addressing delivery of mail to residents on the weekend. 1. During the resident council meeting on 05/06/25, at 2:00 P.M., the residents in attendance said mail was only delivered to residents Monday through Friday and was not delivered to the residents on the weekends. The residents said they would like to receive any mail that comes in on Saturdays if possible. The residents said mail was only delivered on Saturdays if the Activity Director was working as the weekend department head. […]

• No harm, potential for more than minimal, patternF679May 9, 2025

  Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet all residents' interests when staff failed to ensure an variety of activities were provided by facility staff on the weekends. A sample of 19 residents and the group interview of seven residents were selected in a facility with a census of 64. Review of the facility's current policy related to activities showed it did not address activities provided by staff for the residents on the weekend. 1. […]

• No harm, potential for more than minimal, patternF678Jul 17, 2023

  Based on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (if the resident wished to receive assistance if his/her heart stopped beating or he/she stopped breathing) was easily accessible to staff in the event of an emergency and failed to ensure the status matched throughout the medical record for three residents (Residents #23, #12 and #125), out of seven sampled residents. The facility census was 74. Review showed the facility did not provide a written policy regarding the documentation of residents' preferred code status. 1. […]