Saint Luke Lutheran Home relocated Resident #121 in October without notifying her son or medical providers, violating federal rules requiring advance notice of room changes. The 129-bed facility's own policy mandates at least one day's notice to residents and their representatives before any room assignment change.
The resident had lived at the facility since June 2023 on the secured memory care unit. Her diagnoses included acute kidney failure, dementia, and unspecified psychosis.
Licensed Practical Nurse #459 discovered the bed bugs and immediately notified the prior Director of Nursing #494. The DON told her he would handle family notification, but never did.
A progress note dated October 10 at 11:13 a.m. recorded only that the patient was moved from one room to another and was showered and changed. The medical record contained no indication that her representative received notification of the room change.
The resident's son learned about the move only when two female staff members called him November 18, asking whether he had been notified about his mother's room change due to bed bugs.
"He reported he thought it was weird and told them he was not notified of the room change due to bed bugs," inspectors wrote. "The son stated the DON apologized for the poor communication."
During interviews November 19, both of the resident's nurse practitioners confirmed the facility never notified them about the room change. Nurse Practitioner #501 and Nurse Practitioner #500 each told inspectors they received no communication about the bed bug-related move.
The resident herself seemed content with the change. When inspectors interviewed her November 19 at 6:38 a.m., she said she had a room change in October due to bed bugs and liked her new room.
Her quarterly assessment from earlier this year showed she scored 14 out of 15 on the Brief Interview Mental Status exam, indicating intact cognition despite her dementia diagnosis.
The former Director of Nursing #495 told inspectors via phone interview that the room change occurred right before he left his position. He said he was told the notification "was taken care of," but clearly it wasn't.
The facility's Room Change/Roommate Assignment policy, revised in March 2021, explicitly states that prior to changing a room or roommate assignment, all parties involved in the change must receive at least one day's notice. This includes both residents and their representatives.
The violation represents what inspectors classified as "minimal harm or potential for actual harm" affecting few residents. But for this family, the failure meant learning about their loved one's living situation from a belated phone call rather than proper advance notice.
The Licensed Practical Nurse who discovered the bed bugs confirmed she did not notify the resident's family about the room change, following protocol by reporting to her supervisor instead. That supervisor's failure to follow through left the family in the dark for weeks.
Federal complaint number 2646189 triggered the inspection that uncovered this communication breakdown. The facility must now submit a plan of correction to continue participating in Medicare and Medicaid programs.
The case illustrates how administrative failures can leave families disconnected from their loved ones' care, even when the underlying reason for change—moving away from a bed bug infestation—was medically appropriate. The resident adapted well to her new room, but her family's right to know about the change was ignored entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Saint Luke Lutheran Home from 2025-11-24 including all violations, facility responses, and corrective action plans.