St Luke Lutheran Nursing Home

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

and considerate manner, and that they are always treated with dignity and respect in all interactions. You need to explain what you are doing to the resident while providing cares so they know what you are doing and so you don't come across as being rude or rough. The document was signed by the Administrator and Assistant Director of Nursing. An untitled policy last revised November 2016 identified the resident has a right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger

the health or safety of the resident or other residents.In an interview on 9/2/25 at 3:06 PM, the Director of Nursing (DON) reported she expected staff to treat all residents with dignity and respect. The DON reported submitting all information regarding Staff C, had no further documentation regarding Staff C, and couldn't recall if other incidents were reported.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Luke Lutheran Nursing Home

1301 Saint Luke Drive Spencer, IA 51301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record review, observation, staff interview and facility policy review the facility failed to provide privacy of a body during personal cares (Resident #11 and #54). The facility reported a census of 27 residents.Findings include: 1. Observation on 8/27/2025 at 12:43 p.m., Staff C, Certified Nursing Assistant (CNA) and Staff D, CNA assisted Resident #11 into bed. During the transfer with the mechanical lift, staff failed to close the curtains to provide privacy during the transfer. 2. Observation on 8/27/2025 at 9:57 a.m., revealed Staff A, CNA and Staff B, CNA assisted Resident #54 into bed. During the transfer with

the mechanical lift staff failed to close the curtains to provide privacy during the transfer. Review of the facility policy titled Resident Right Guidelines undated revealed close the door to the room when privacy is appropriate. Draw window curtains as well as the privacy curtain between beds. Provide privacy for the resident during cares. Interview on 8/27/2025 at 1:54 p.m., with the Director of Nursing (DON) revealed staff should have the curtains closed when performing transfers.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Luke Lutheran Nursing Home

1301 Saint Luke Drive Spencer, IA 51301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited St Luke Lutheran Nursing Home in SPENCER, IA for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2025-09-04.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of St Luke Lutheran Nursing Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

how you talk to residents or about them in front of the residents and your co-workers. It is my experience that all residents are treated in a kind and considerate manner, and that they are always treated with dignity and respect in all interactions. You need to explain what you are doing to the resident while providing cares so they know what you are doing and so you don't come across as being rude or rough. The document was signed by the Administrator and ADON.In an interview on 8/28/25 at 9:50 AM, the ADON reported she didn't recall all the details of the meeting with the Administrator and Staff C, CNA. The ADON stated, it was all the way back in February, that's hard to remember. The ADON reported meeting with Staff C about her gruff voice, then made plans for Staff C's work assignments to be in the same hall as the ADON's office.

When asked to provide documentation related to resident care incidents and the meeting with Staff C, the ADON reported she doesn't keep documentation of any incident. The ADON explained once she reported to the Administrator or DON, she destroys her documentation. In an interview on 8/28/25 at 10:28 AM, when asked if the Administrator received any typed letter in February regarding Staff C, CNA and concerns with resident care. The Administrator stated, I remember getting something but I don't know if it was one of

the letters we already gave you, or something else, or I may have gotten rid of it. When asked if he is required to keep documentation, the Administrator stated, I don't know am I? When asked if the [DATE REDACTED] documentation concerning Staff C occurred in reaction to receiving a concern, the Administrator stated, yes but I don't remember what was said. I looked through my notes and I didn't see anything. In an interview on 9/2/25 at 3:06 PM, the DON reported submitting all information regarding Staff C, had no further documentation regarding Staff C, and couldn't recall if other incidents were reported. The DON stated, I know we are supposed to report allegations of abuse within two hours, but I already gave you all the documentation I had. I don't remember anything else that was reported. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 identified all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting allegations of abuse to the Administrator, or designated representative. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Luke Lutheran Nursing Home

1301 Saint Luke Drive Spencer, IA 51301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited St Luke Lutheran Nursing Home in SPENCER, IA for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-04.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of St Luke Lutheran Nursing Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

Federal health inspectors cited St Luke Lutheran Nursing Home in SPENCER, IA for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-09-04.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of St Luke Lutheran Nursing Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

Resident #70's fall investigation dated 7/31/25 documented the resident fell in the bathroom when washing her hands. The Fall Scene Investigation Report completed by Staff G, Certified Nurses Aide documented

she left Resident #70 unattended at the bathroom sink to go into the room to get her wheelchair and the resident fell. It further documented the root cause was the resident was left unattended and staff not using

a gait belt.

On 8/28/2025 at 9:52 AM, the Director of Nursing reported staff are made aware of care plan changes with

a care plan alert and it is at the nurses station to follow. Staff should not have left Resident #70 unattended

in the bathroom.

The facility policy titled Falls-Clinical Protocol dated 8/10/2008 documented staff and physicians will identify pertinent interventions to try to prevent subsequent falls. It lacked documentation of follow up to ensure interventions are being done.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited St Luke Lutheran Nursing Home in SPENCER, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-04.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of St Luke Lutheran Nursing Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.

Federal health inspectors cited St Luke Lutheran Nursing Home in SPENCER, IA for a deficiency under regulatory tag F-F0943 during a standard health inspection conducted on 2025-09-04.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of St Luke Lutheran Nursing Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-17.