St Lukes Home

In the surveyor’s words

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

• Actual harm, isolatedF760Feb 9, 2023

  Based on record review, review of professional reference, review of facility policy, and resident and staff interviews, the facility failed to follow professional standards for medication administration for 1 of 1 sampled resident (Resident #33) who experienced adverse side effects as a result of a significant medication error. Failure of staff to administer medications utilizing safe administration practices resulted in an adverse reaction to Resident #33's physical health/safety, and affected the resident's psychosocial well being. Findings include: Berman, Snyder, Kozier, and Erb's, Fundamentals of Nursing Concepts, Process, and Practice, 10th Edition, Copyright 2016 by Pearson Education, Inc., New Jersey, page 769-771, stated, . […]

• No harm, potential for more than minimal, patternF880Jun 17, 2026

  Based on observation, policy review, and staff interview, the facility failed to follow infection control standards for 3 of 5 sampled residents (Resident #7, #12, and #71) observed during cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to spread infections throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/16/26. This policy, revised on 04/22/26, stated, . Staff will perform hand hygiene . using proper technique consistent with accepted standards of practice . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE) . Before and after handling clean or soiled dressings . Before performing resident cares . […]

• No harm, potential for more than minimal, patternF812Mar 30, 2022

  Based on observation, review of facility policy, record review, review of professional reference, and staff interview, the facility failed to ensure appropriate concentration levels of sanitizer solution and failed to ensure cupboards/appliances remained locked in 1 of 4 kitchenettes (Western Unit). Failure to consistently test concentration levels of sanitizing solutions may result in unsanitary surfaces and a sanitizer concentration that is either too weak to sanitize or too strong and failure to ensure cupboards/appliances remained locked may result in chemical contamination or injury and has the potential for spread of foodborne illness to residents, staff, and visitors. Findings include: The Food Code, U.S. Public Health Service, Food and Drug Administration, U.S. […]

• No harm, potential for more than minimal, patternF880Mar 30, 2022

  TRANSMISSION BASED PRECAUTIONS 1. Based on observation, facility policy review, and staff interview, the facility failed to follow infection control practices for 2 of 2 sampled residents (Resident #1 and #2) on Transmission-based precautions (TBP). Failure to follow infection control practices related to proper procedure for personal protective equipment (PPE) usage may result in the spread of infection to residents, staff, and/or visitors. Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 03/30/22. This policy, revised 11/01/21, stated, . Isolation Protocol (Transmission-Based Precautions): a. […]

• No harm, potential for more than minimal, patternF641Sep 2, 2021

  THIS IS A REPEAT DEFICIENCY FORM THE STANDARD SURVEY CONDUCTED ON 01/16/20 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 6 of 21 sampled residents (Resident #7, #26, #31, #65, #71, and #78), and 2 supplemental residents (Resident #9 and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. […]