Resident 207, who has moderate cognitive impairment and requires staff assistance with toileting, developed a urinary tract infection that went untreated while staff failed to document the family's initial concerns or follow up on the reported symptoms.
The 127-bed facility's own records show no evidence that Licensed Practical Nurse 333 documented the family's September 24 call about burning urination symptoms. The nurse told inspectors during an October 9 interview that she had notified the nursing coordinator and ordered urinalysis testing, but no such order appears in the medical record until four days later.
Staff finally documented the resident's urinary complaints on September 28 at 1:12 p.m., when nursing notes recorded that Resident 207 complained of burning during urination. A physician then ordered urinalysis with culture and sensitivity testing that same day.
But the facility delayed obtaining the urine sample for another three days. The specimen wasn't collected and sent to the laboratory until October 1, despite the resident's continued symptoms and the standing physician's order.
Laboratory results came back on October 6 at 2:14 p.m., showing Resident 207 tested positive for providencia stuartii bacteria. The physician ordered Bactrim DS antibiotic treatment that same day, finally beginning treatment 12 days after the family first reported symptoms to nursing staff.
The resident, who was admitted to Saint Luke Lutheran Home in February with chronic atrial fibrillation, hypothyroidism and congestive heart failure, remained incontinent of urine and dependent on staff for toileting assistance throughout the ordeal.
Medical records show no evidence that nursing staff followed up with the family on September 25, 26, or 27 about the reported urinary symptoms, despite the family's initial concerns about burning during urination.
During the October 9 inspection interview, the Director of Nursing confirmed that medical records contained no evidence LPN 333 had addressed the family's September 24 concerns. The nursing director verified that symptoms weren't addressed until September 28, and acknowledged the three-day delay in obtaining the ordered urine specimen.
Federal inspectors found the facility failed to provide appropriate care for residents with bladder incontinence and failed to prevent urinary tract infections through timely assessment and treatment. The violation affected one of three residents reviewed for urinary tract infection care during the complaint investigation.
Saint Luke Lutheran Home's handling of Resident 207's case violated federal requirements for appropriate catheter care and urinary tract infection prevention. The facility's 127 residents depend on staff to recognize and respond promptly to symptoms of infection, particularly for those with cognitive impairment who may not be able to clearly communicate their discomfort.
The inspection was conducted in response to Complaint Number 2637235. Resident 207's urinary tract infection, caused by providencia stuartii bacteria, required antibiotic treatment that could have begun eight days earlier if staff had acted on the family's initial report of symptoms.
The four-day gap between the family's call and staff documentation, followed by the three-day delay in collecting the ordered urine specimen, extended the resident's discomfort and delayed necessary medical treatment for a condition that can become serious in elderly patients with multiple health conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Saint Luke Lutheran Home from 2025-10-14 including all violations, facility responses, and corrective action plans.