Inspection Reports for
St Luke Lutheran Nursing Home

The facility was found to have multiple deficiencies including failure to respect residents' dignity, failure to provide privacy during personal care, failure to timely report allegations of abuse, and failure to ensure safe mechanical lift transfers resulting in an immediate jeopardy fall. The facility also failed to prevent falls by not following care plans for supervision.

The facility was found deficient in multiple areas including failure to respect residents' dignity, failure to provide privacy during care, improper use of physical restraints, failure to timely report abuse allegations, incomplete bed hold documentation, inaccurate resident assessments, unsafe mechanical lift transfers causing a resident fall with injury, failure to prevent falls by supervision, failure to follow infection control protocols, and failure to ensure staff completed mandatory abuse reporter training.

The complaint investigation was triggered by an incident on 5/7/24 when Resident #16 left the facility undetected through a disabled door alarm, was missing for over two hours, and returned with injuries. The Immediate Jeopardy was identified on 8/21/24 and removed the same day after corrective actions.

The facility failed to ensure door alarms were activated, resulting in Resident #16 leaving the building unnoticed and sustaining injuries. Additionally, staff failed to properly secure Resident #23 during a sit-to-stand mechanical lift transfer.

The facility was found deficient in multiple areas including resident dignity and privacy, incomplete resident records, inadequate care plan revisions, pressure ulcer care, accident hazard prevention, respiratory care, and infection control practices during a COVID-19 outbreak.

The complaint involved allegations that the facility failed to timely report suspected abuse, failed to investigate abuse allegations properly, failed to respond promptly to call lights, and failed to cover food trays when delivering meals. The facility reported a census of 75 residents. The abuse allegation was not substantiated as the resident denied being hit. The facility did not separate the staff and resident during the investigation. Call lights were documented to have long delays in response. Food trays were observed uncovered when delivered to residents' rooms.

The facility failed to timely report an allegation of abuse, failed to investigate abuse allegations and separate involved parties, failed to ensure call lights were answered within 15 minutes, and failed to cover food trays when delivering meals to residents' rooms. The facility reported a census of 75 residents.

Complaints #119922-C and #120153-C were substantiated. The facility failed to report an allegation of abuse timely and failed to investigate abuse allegations properly. Resident #5 denied abuse occurred during interviews, but the facility did not meet reporting requirements.

The facility failed to report an allegation of abuse within the required timeframe and failed to investigate allegations of abuse thoroughly. The facility also failed to ensure call lights were answered timely and failed to maintain food safety standards. Staff education and monitoring plans were implemented to address these issues.

The facility failed to follow a physician's bowel protocol order for one resident, did not provide appropriate catheter care for another resident, failed to respond timely to call lights for multiple residents, and served food and drinks at unsafe temperatures.

Investigation of facility self-report incident #114811-1 was conducted and was not substantiated.

The facility was found to have deficiencies in meeting professional standards of care, including failure to follow physician orders for bowel protocols, inadequate care to prevent infections related to urinary catheters, insufficient nursing staff to timely respond to call lights, and failure to maintain proper food and beverage temperatures. Plans of correction were provided for all deficiencies.

The complaint investigation found that the fall was accidental and not likely preventable according to the resident's physician. Staff interviews confirmed the CNA turned her back to the resident and failed to maintain grip on the gait belt, contributing to the fall.

The facility failed to provide necessary nursing supervision for one resident who fell and sustained a serious injury, specifically a closed subcapital fracture of the left hip. Staff interviews and documentation confirmed the fall occurred when a CNA turned her back to the resident and did not maintain proper assistance.

Investigation was complaint-related involving multiple complaints and self-reported incidents. The fall was identified as accidental and not likely preventable by the resident's physician.

The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall with serious injury.

Complaint #104063-C was substantiated.

The facility was found deficient in providing adequate ADL care, specifically bathing for dependent residents, quality of care related to wound assessment and treatment, and ensuring a safe environment free of accident hazards. Deficiencies were documented with detailed resident case reviews and staff interviews.

The visit was triggered by investigation of incident #99017, which was not substantiated.

The facility was found deficient in care plan timing and revision, bowel/bladder incontinence care, catheter and UTI prevention, and infection prevention and control. Deficiencies included failure to create individualized care plans, improper incontinence care, failure to perform hand hygiene, and inadequate infection control practices.

The facility was found deficient in multiple areas including resident rights, abuse prevention policies, comprehensive care plans, provision of ADL care, nurse aide registry verification, in-service training, and infection prevention and control. Specific issues included failure to assure dignity for one resident, incomplete training for staff, missing physician orders, inadequate incontinent care, and lapses in infection control practices.