St Lukes Home

Based on observation, review of facility policy, and staff interview the facility failed to follow standards of infection control for 1 of 4 sampled residents (Resident #62) observed for morning cares. Failure of staff to perform hand hygiene after removing gloves has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 04/10/25. This policy, revised 10/30/24, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Observation on 04/08/25 at 10:09 a.m. showed Resident #62 resting in bed wearing oxygen per nasal cannula and his upper denture sitting on the over the bed table. Two certified nurse aides (CNAs) (#1 and #2) entered the resident's room, performed hand hygiene, donned gloves, assisted the resident to sit on the edge of the bed, placed a gait…

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 and review of facility policy, the facility failed to promote privacy and confidentiality of medication administration records (MAR) on 1 of 2 Units (Badlands Unit) observed for medication administration. Failure to close the MAR may result in unauthorized viewing of resident records by other residents, unlicensed staff, and/or visitors. Findings include: Review of facility policy titled Confidentiality of Social and Medical Information occurred on 02/08/24. This policy, dated 10/15/17, stated, . The facility should keep confidential all information contained in a resident's records, regardless of the form of storage or location of the record, . Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure . Observation during medication administration on 02/07/24 showed the medication cart unattended with a resident's MAR visible on the screen during the following times: * 12:16 p.m. to 12:18 p.m. * 12:20 p.m. to 12:22 p.m. * 3:50 p.m. to…

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 THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/09/23. Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 4 sampled residents (Resident #7 and #51) reviewed with alarms. Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, Section P: Restraints and Alarms, page P-10, stated, . Identify all alarms that were used at any time (day or night) during the 7-day look-back period.Code 0, not used: . Code 1, used less than daily: . Code 2, used daily: . Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident's…

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, record review, review of standing orders, and staff interview, the facility failed to follow professional standards regarding physician's orders for 1 of 2 sampled residents (Resident #4) and 1 closed record (Resident #82) reviewed for insulin orders. Failure to follow the physician's order regarding notification of high blood sugar levels has the potential to result in adverse events. Findings include: - Review of Resident #4's medical record occurred on all days of survey. Medical diagnoses included Type 2 diabetes mellitus. Observation on 02/07/24 at 11:05 a.m. showed a nurse (#3) checked Resident #4's blood sugar with a glucose meter and obtained a result of 336 milligrams per deciliter (mg/dL). Review of the Medication Administration Record (MAR) for sliding scale insulin identified . Per Sliding Scale . Special Instructions: Call PCP [primary care provider] if Blood sugar greater than 300 [mg/dL] . During an interview on 02/07/24 at 3:07 p.m., the nurse (#3) who obtained Resident #4's blood sugar and administered the sliding scale insulin stated she did…

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 record review and staff interview, the facility failed to ensure residents' records contained the hospice election form for 2 of 2 sampled residents (Resident #72 and #189) receiving hospice services. Failure to obtain this document limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: - Review of Resident #72's medical record occurred on all days of survey and identified the resident elected hospice services on 12/06/23. The medical record lacked the hospice election form. - Review of Resident #189's medical record occurred on all days of survey and identified the resident elected hospice services on 01/30/24. The medical record lacked the hospice election form. During an interview on 02/08/24 at 10:33 a.m., an administrative nurse (#1) confirmed the medical record lacked the hospice election form for Resident #72 and #189.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to notify the resident's physician of a change in condition for 1 of 1 resident (Resident #33) who experienced low blood pressure, weakness and shortness of breath. Failure to notify the physician of these changes may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notify of Changes occurred on 02/09/23. This policy, dated 04/21/22, stated, . The purpose of this policy is to ensure the facility promptly . consults the resident's physician; . when there is a change requiring notification. Compliance Guidelines: The facility must . consult with the resident's physician when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical . condition such as deterioration in health . During an interview on 02/08/23 at 3:38 p.m. Resident #33 indicated about two weeks ago a nurse gave her the wrong medications.…

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 THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 09/02/21 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to complete Minimum Data Sets (MDSs) that accurately reflected the residents' status for 2 of 18 sampled residents (Resident #34, and #63). Failure to accurately code the MDS may negatively affect the development of comprehensive care plans and the care provided to the residents. Findings include: Section A: Identification Information The Long-Term Care Facility RAI Manual, revised October 2019, pages A-21 to A-23, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding instructions: Code 0, no, and skip to A1550 . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . - Review of Resident #34's medical record occurred on all days of survey. Diagnoses included schizoaffective…

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, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 6 residents (Resident #22 and #46) observed during medication pass. Three medication errors occurred during staff administration of 28 medications, resulting in a 10% error rate. Failure to ensure medications are administered correctly may result in an adverse side effects. Findings include: Review of the facility policy titled Use Of Insulin Pens occurred on 02/09/23. This policy, dated 12/14/16, stated, . Insulin pens will be prepared and primed prior to actual dose administration to ensure expelling of air and accuracy of dosage . After needle is in place, do an air shot before injection . To perform air shot do the following . Dial two units . Hold syringe with needle pointing up and tap reservoir gently to remove air bubbles to tip of needle . Press the push button on syringe . until a drop of insulin appears. - Observation on 02/09/23 at 6:53 a.m. showed a licensed nurse (#1) prepared Resident #46's Lantus…

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, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 10 sampled residents (Residents #11 and #68) observed during perineal cares and/or dressing change. Failure to follow infection control standards has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: DRESSING CHANGE Review of the facility policy titled Wound Care Dressing Change occurred on 02/13/23. This policy, dated October 2022, stated, . remove soiled dressing. Remove soiled gloves. Perform hand hygiene. Put on clean gloves. Observation on 02/07/23 at 8:15 a.m. showed a nurse (#5) removed Resident #11's right foam heel protector and a blue absorbent pad, and without changing gloves, measured the pressure ulcer, opened the promogram prism (wound treatment), used gloved hands to form it to the open area, and then replaced the absorbed pad and the foam heel cushion. The nurse (#5) failed to remove her gloves and perform hand hygiene after removing the foam heel pad 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.