St Luke Lutheran Nursing Home
St Luke Lutheran Nursing Home in Spencer, IA — inspection on September 4, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Director of Nursing. An untitled policy last revised November 2016 identified the resident has a right
endanger the health or safety of the resident or other residents.In an interview on 9/2/25 at 3:06 PM,
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.
165484 09/04/2025
St Luke Lutheran Nursing Home 1301 Saint Luke Drive Spencer, IA 51301
Observation on 8/27/2025 at 12:43 p.m., Staff C,
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.
165484 09/04/2025
St Luke Lutheran Nursing Home 1301 Saint Luke Drive Spencer, IA 51301
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.
know what you are doing and so you don't come across as being rude or rough.
The document was
it was all the way back in February, that's hard to remember.
The ADON reported meeting with Staff C
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] 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.
165484 09/04/2025
St Luke Lutheran Nursing Home 1301 Saint Luke Drive Spencer, IA 51301
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.
wheelchair and the resident fell. It further documented the root cause was the resident was left
jeopardy to resident health or safety 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
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.
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.