St John Lutheran Home

Based on observation, interview, and document review, the facility failed to ensure kitchen and walk-in cooler was clean and free of food-like debris. In addition, kitchen staff failed to consistently log dishwasher temps to ensure proper sanitation and failed to date meat when placed in the walk-in cooler to thaw. This had the potential to affect all 51 residents. Findings include: FOOD STORAGE/KITCHEN CLEANLINESSObservation on 6/1/26 at 10:55 a.m., in the kitchen identified:The stove-top had food crumbs and a dried liquid on and between the burners and the wall behind the stove had food debris splashed upon the wall. A utility box mounted on the wall to the right of the stove was covered with a heavy layer of dust, mixed with food particles.A food prep counter near the sink had a radio that was covered in dust and food debris splatter.The office area connected to the kitchen had a countertop with a microwave, toaster, open partially used container of peanut butter, a large partially used plastic container of butter, and half of a loaf of bread. The countertop also had phone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance Program Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 51 residents. Findings include: Review of the designated quarterly QAPI meetings from June 2025 through April 2026 identified facility departments were submitting data for review by the committee, but the minutes lacked evidence of measurable goals, discussion of the data submitted, and a plan of action for improvement. Examples included:The June 18, 2025, QAPI meeting minutes identified the facility monitored areas such as:Falls: 13 falls occurred, which was down from the previous month with 4 residents (unknown) having repeated falls. The goal was to decrease falls. There were no major injuries noted with actions to continue to review each fall and new intervention in place. There was no indication who the residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to follow physician orders to measure a pressure ulcer weekly and follow their policy and procedure on documenting pressure ulcer care for 1 of 1 sampled resident (R8).Findings include: R8's quarterly, Minimum Data Set (MDS) assessment, accepted on 5/19/26 identified R8's cognition was moderately impaired, and she required substantial assistance with care, bed mobility and transfers. R8 had a life expectancy of 6 months or less and was on hospice. R8 had pain and within the assessment period, had reported her pain was severe. R8 took scheduled pain medication and as-needed pain medication. R8 was identified as having a Stage 2 pressure ulcer with a pressure relieving device in her chair and on the bed. Observation and interview on 6/2/26 at 8:55 a.m., with registered nurse (RN)-A who performed a dressing change to R8's thoracic spine identified RN-A removed the old dressing and cleansed the area. The wound measured 0.7 centimeters (cm) x 0.4 cm. RN-A described the wound as superficial with a red wound bed and well-defined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to perform antibiotic stewardship to include a system for monitoring and reducing antibiotic resistance. In addition, the facility failed to follow their policy on antibiotic stewardship and conduct an antibiotic timeout (ATO) for 1 of 3 sampled residents (R52). Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the resident current symptoms and any laboratory results to identify medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review the facility failed to ensure the kitchen ceiling tiles were kept in a clean and sanitary manner and free of dust and debris. This had the potential to affect all 46 residents residing in the facility. Findings include: On 5/13/25 at 9:08 a.m., two ceiling tiles located approximately six feet from the steam table were observed with gray, fuzzy material hanging from them. Directly beneath these ceiling tiles were two metal meal carts. At the time of observation, cook (C)-A was interviewed and confirmed the presence of the gray fuzzy material on the ceiling tiles, acknowledging the condition was unclean and unacceptable. C-A stated that kitchen staff were responsible for cleaning the ceiling tiles and further confirmed that plated food trays were placed on the metal carts located under the affected ceiling area before being delivered to residents. On 5/13/25 at 10:45 a.m., dietary aide (DA)-A was observed placing plated food onto meal trays located on metal carts situated directly beneath the ceiling tiles with visible gray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview on 5/13/25 at 1:11 p.m., on first floor, NA-A stated staff carried soiled laundry, including resident clothing, bed linens and towels, from resident rooms by hand, down the hallway to a hamper in the tub room if it was soiled resident clothing, or the utility room if it was soiled bed linens or towels. NA-A stated she would do this even if there were a small amount of BM (bowel movement) on the laundry. NA-A stated staff did not place soiled laundry in bags first before carrying it to the hampers. NA-A stated she was careful not to let soiled laundry touch her uniform. Further, NA-A stated she had done that as long as she had worked at the facility. Review of NA-A's orientation checklist dated 8/9/24, did not include instruction on transporting soiled laundry. During an interview on 5/13/25 at 1:29 p.m., on second floor, NA-F stated soiled laundry was carried by hand to either the utility room or tub room, such as resident clothing, towels, washcloths and bed linen. NA-F stated soiled laundry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and implemented to include of post-traumatic stress disorder (PTSD) triggers and interventions for 2 of 2 residents (R10 and R23) who had a diagnosis of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and anxiety. Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure accuracy of measured weights for 1 of 1 resident (R29) reviewed for nutrition. Findings include: R29's face sheet printed on 5/14/25, included diagnoses of diabetes, high blood pressure, and history of stroke. R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. No weight loss and no difficulty swallowing. R29 required substantial assistance or was dependent upon staff for activities of daily living. R29's physician orders dated 12/12/23, indicated regular diet. R29 was not on a diuretic (a medication that increases urine output). R29's care plan dated 3/26/25, indicated R29 had an altered nutritional status related to diabetes and history of stroke. A goal for R29 dated 3/15/24, indicated R29 would have stable weights by estimated date of 6/24/25. Intervention dated 12/18/23, indicated to monitor weight and intake. (The frequency was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with daily maintenance and weekly cleaning for 1 of 1 resident (R23) reviewed for respiratory care and treatments. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), and obstructive sleep apnea (breathing repeatedly stops or become significantly reduced during sleep often due to collapse of the upper airway). R23's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had moderate cognitive impairment, and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. Special treatments included CPAP. R23's plan of care dated 3/11/24, did not include a respiratory plan of care or the use of a CPAP machine. R23's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to identify and document the trauma-related history, post-traumatic stress disorder (PTSD), known triggers and lacked a system or process for completing trauma assessments for 2 of 2 residents (R10 and R23) with a known history of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 1 of 1 ice machines used for resident consumption. This had the potential to affect all 49 residents who resided in the facility. Findings include: During an observation on 4/16/24 at 10:39 a.m., noted a Manitowoc brand, counter-top style ice machine in the first floor resident ice machine. During an interview on 4/15/24 at 11:35 a.m., dietary supervisor (DS)-B stated dietary staff wiped down the outside of the ice machine located in the first-floor dining room but did not clean the inside. During an interview on 4/17/24 at 11:17 a.m., dietary aide (DA)-A stated she cleaned the ice machine using hot water and a long narrow brush to clean a long, narrow PVC pipe laying horizontal alongside the bottom of the ice machine. DA-A stated dietary staff did not clean the inside of the ice machine; didn't empty out the ice or do anything else to it. DA-A verified the ice machine was used for resident consumption. Reviewed Manitowoc ice machine Use & Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure basic infection control measures were followed when 1 of 1 resident (R41's) urinary drainage bag was observed resting on the floor. Findings include: R41's diagnosis list printed on 4/17/24, included history of pulmonary emboli (when arteries are blocked by a blood clot). R41's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and dependency upon staff for most activities of daily living. R41's physician orders dated 9/8/23, indicated indwelling urinary catheter. R41's care plan dated 9/15/23, indicated Foley (describes the type of catheter) catheter management per MD (medical doctor) orders and facility protocol. During an observation on 4/15/24 at 1:39 p.m., observed R41's urinary drainage bag hooked to the side pocket of his cloth recliner, resulting in the bottom of the bag, including the urinary drainage valve, to rest on the floor. During an observation on 4/16/24 at 8:18 a.m., R41 was in his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.