St Lukes Lutheran Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 1, 2023

  Based on observation, interview, and document review, the facility failed to ensure dishwashing sanitization for 1 of 1 dishmachine was appropriately monitored. Findings include: During an interview and observation on 2/27/23, at 6:55 a.m., the initial kitchen tour was conducted with culinary services director (CSD). The dishmachine was observed and CSD stated dishes were sanitized by chemical disinfection with chlorine. During an interview and observation on 3/1/23, at 8:40 a.m., the dishmachine log, titled Dishwasher Temperature and Sanitizer Log, located in the dishmachine room, was observed to have sanitizer concentrations of chlorine documented below the required 50 to 200 ppm (parts per million). Some readings on the log were 0, some were 10, 50, 100 or 200 ppm. […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2021

  Based on observation, interview, and document review, the facility failed to ensure dishwashing sanitization for 1 of 1 dishmachine was appropriately monitored. In addition, the facility failed to date-mark opened containers of food in 1 of 1 kitchen refrigerator, and to ensure pans were completely dry before storing. Furthermore, the facility failed to ensure dietary staff received required training on an on-going basis for 3 of 3 staff: culinary services director (SD)-D, assistant director of culinary services (ADCS)-E, and cook (C)-A. This had the potential to affect all 64 residents who were served food from the kitchen. […]

• No harm, potential for more than minimal, patternF809Mar 20, 2024

  Based on interview and document review, the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime for 4 of 8 residents (R40, R25, R21, R12) who voiced a concern. This had the potential to affect all 51 residents who resided in the facility. Findings include: During an interview on 3/18/24 at 12:33 p.m., R40, who's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, stated she had been a resident at the facility since 2/27/24, and had not been offered a snack after dinner and before bedtime. R40 stated she didn't know if she could get a snack if she asked and would like one sometimes. […]

• No harm, potential for more than minimal, patternF880Oct 28, 2021

  Based on observation, interview and document review, the facility failed to ensure infection control measures were maintained for indwelling urinary catheter care for 1 of 1 resident (R43) reviewed for catheter care. Furthermore, the facility failed to ensure hand hygiene was performed during resident care and meal-tray passes for 3 of 3 residents (R43, R54 and R41) observed for infection control practices. Findings include: R43's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R43 was cognitively intact, had adequate hearing and vision, clear speech, was able to make herself understood and could understand others. […]

• No harm, potential for more than minimal, isolatedF684Jun 23, 2026

  Based on interview and document review, the facility failed to assess a significant weight gain, obtain a reweigh, and notify the physician 1 of 1 resident (F54) reviewed for weight gain. Findings include: R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, required partial/moderate assistance with personal hygiene and sit to stand, a weight of 213 pounds, no Gain of 5% or more in the last month or gain of 10% or more in last 6 months, received a diuretic (help remove extra fluid from the body), and diagnoses included hypertension (high blood pressure) and dyspnea (shortness of breath).R54's care plan dated 5/8/26, indicated potential for fluid imbalance R/T (related to) use of diuretic medications due to edema (swelling) and interventions… […]