Saint Luke Lutheran Home

Based on medical record review and interview the facility failed to timely assess and obtain necessary treatment for Resident #207 for a urinary tract infection.

This affected one resident (#207) of three residents reviewed for urinary tract infection.

The facility census was 127.

Findings include: Review of Resident #207's medical record revealed an admission date of 02/22/25 with diagnoses including chronic atrial fibrillation, hypothyroidism and congestive heart failure.

Review of the Resident #207's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 08/29/25 revealed the resident had moderate cognitive impairment and was dependent upon staff for assistance with toileting and always incontinent of urine.

Review of the nursing progress notes, dated 09/28/25 at 1:12 P.M. revealed Resident #207 complained of burning during urination and a new order was obtained to straight cath (inserting catheter into the bladder to obtain urine) for urine sample and the family was notified.

Review of the nursing notes revealed no evidence of any documentation of family concerns related to symptoms of a urinary tract infection (i.e. urinary burning) on 09/24/25 or subsequent family follow up with staff members on 09/25/25, 09/26/25 or 09/27/25.

Review of the physician orders revealed on 09/28/25 the urinalysis with culture and sensitivity was ordered by the physician.

The urine sample was obtained and sent to the lab on 10/01/25.

Review of the urinalysis with culture and sensitivity results, which were reported on 10/06/25 at 2:14 P.M., revealed Resident #207 tested positive for providencia stuartii (bacteria).

Review of the physician orders revealed Bactrim DS (antibiotic) was ordered beginning 10/06/25 (12 days after the resident's representative reported the resident's symptoms to facility staff and eight days after the facility documented the resident had complaints of burning during urination). On 10/09/25 at 11:54 A.M. interview with Licensed Practical Nurse (LPN) #333 revealed on 09/24/25 Resident #207's representative notified her the resident complained of burning upon urination. LPN #333 indicated she notified the nursing coordinator of the concerns and ordered a urinalysis with culture and sensitivity. LPN #333 verified there was no evidence of documentation in the medical record of Resident #207's urinary burning concerns or evidence of a urinalysis with culture and sensitivity ordered on 09/28/25.

Interview with the Director of Nursing on 10/09/25 at 12:00 P.M. verified the medical record contained no evidence LPN #333 addressed the concerns reported by Resident #207's representative on 09/24/25 and the symptoms were not addressed until 09/28/25 when an order for a urine specimen with culture and sensitivity were ordered.

However, the urine specimen was not obtained until 10/01/25.

This deficiency represents non-compliance investigated under Complaint Number 2637235.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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