Facility profile · CCN 365521
Saint Luke Lutheran Home
70 federal citations on record , including 1 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $97,793.
Record summary
Federal record · Q1 202670
Total citations
39
Last 3 years
4
Actual harm+
2
Federal penalties
$97,793
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
70 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Jan 30, 2026 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Complaint |
| Jan 30, 2026 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Complaint |
| Jan 5, 2026 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jan 5, 2026 | F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Complaint |
| Jan 5, 2026 | F583 | Keep residents' personal and medical records private and confidential. | D | Complaint |
| Nov 24, 2025 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Nov 24, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Complaint |
| Nov 24, 2025 | F559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | D | Complaint |
| Oct 14, 2025 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint |
| Sep 11, 2025 | F908 | Keep all essential equipment working safely. | F | Complaint |
| Sep 11, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Complaint |
| Sep 11, 2025 | F809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | D | Complaint |
| Sep 11, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Sep 11, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Sep 11, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Sep 11, 2025 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Complaint |
| Aug 4, 2025 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Complaint |
| Aug 4, 2025 | F837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | F | Complaint |
| Aug 4, 2025 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | Complaint |
| Aug 4, 2025 | F805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | E | Complaint |
| Aug 4, 2025 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Complaint |
| Aug 4, 2025 | F744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | J | Complaint |
| Aug 4, 2025 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint |
| Aug 4, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Complaint |
| Aug 4, 2025 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint |
| Aug 4, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Aug 4, 2025 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Complaint |
| Aug 4, 2025 | F641 | Ensure each resident receives an accurate assessment. | D | Complaint |
| Aug 4, 2025 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Aug 4, 2025 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Aug 4, 2025 | F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D | Complaint |
| Aug 4, 2025 | F567 | Honor the resident's right to manage his or her financial affairs. | D | Complaint |
| Aug 4, 2025 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint |
| May 12, 2025 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | Complaint |
| May 12, 2025 | F732 | Post nurse staffing information every day. | C | Complaint |
| May 12, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| May 12, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| May 12, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | F | Complaint |
| Mar 10, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Jan 30, 2023 | F887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | D | Standard |
| Jan 30, 2023 | F881 | Implement a program that monitors antibiotic use. | D | Standard |
| Jan 30, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Jan 30, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard |
| Jan 30, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard |
| Jan 30, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard |
| Feb 6, 2020 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Feb 6, 2020 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard |
| Feb 6, 2020 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard |
| Feb 6, 2020 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Feb 6, 2020 | F730 | Observe each nurse aide's job performance and give regular training. | F | Standard |
| Feb 6, 2020 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Feb 6, 2020 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Feb 6, 2020 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Feb 6, 2020 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Feb 6, 2020 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard |
| Feb 6, 2020 | F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D | Standard |
| Jan 16, 2019 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Jan 16, 2019 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Jan 16, 2019 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard |
| Jan 16, 2019 | F791 | Provide or obtain dental services for each resident. | D | Standard |
| Jan 16, 2019 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Jan 16, 2019 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Jan 16, 2019 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Jan 16, 2019 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Jan 16, 2019 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Jan 16, 2019 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard |
| Jan 16, 2019 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Jan 16, 2019 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Jan 16, 2019 | F610 | Respond appropriately to all alleged violations. | D | Standard |
| Jan 16, 2019 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 1 civil money penalties totaling $97,793 and 1 payment-denial actions spanning 44 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| May 12, 2025 | Fine | $97,793 | — |
| May 12, 2025 | Payment Denial | — | Aug 12, 2025 · 44 days |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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