Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke Living Center during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident and Common Areas: Surveyors observed multiple resident room walls and bathroom doors with missing paint, exposed wood, exposed metal, and exposed sheetrock. Hallway and utility area ceiling tiles were stained, broken, flaking, and in some places bulging with open access above the drop ceiling. Admin staff and maintenance stated they were unaware of several of the issues, and maintenance reported ceiling tiles were replaced on a spot-check basis as noticed.
Failure to document informed consent for a psychotropic medication. A resident with Alzheimer’s disease, anxiety, psychotic disorder, major depressive disorder, and severely impaired cognition was prescribed Buspar for anxiety, but the clinical record lacked evidence that the resident or representative was informed about the risks and benefits. Staff could not locate the consent or any note showing the medication was discussed.
A resident with Alzheimer’s disease, anxiety, psychotic disorder, and major depressive disorder was receiving Seroquel 25 mg for psychotropic use, but the MDS showed no GDR attempt and no physician documentation that a GDR was contraindicated. The CAA, care plan, physician orders, and drug regimen reviews all reflected ongoing Seroquel use, and staff confirmed there was no GDR request, no attempt, and no risk-versus-benefits statement for the antipsychotic.
A resident with heart failure and dementia was sent to the hospital after becoming short of breath with wheezing and diminished breath sounds, but the EMR lacked written transfer notification to the resident or representative and lacked documentation that the ombudsman was notified. The record also showed no documentation that the bed hold was explained or provided, and staff stated the bed hold process and written notice requirements were not followed.
Incomplete Baseline Care Plan for Resident with Dementia and Wandering Behavior. A resident with dementia, FTT, HTN, and atrial fibrillation did not have a completed baseline care plan after admission. The plan was unsigned and missing key sections for fall risk, elopement/WanderGuard status, and social services/discharge planning, and it incorrectly listed an antipsychotic medication. Staff said the charge nurse or ADON usually reviews the baseline care plan with the resident or representative, but the representative left early and no alternate attempt was made.
Failure to disinfect a glucometer after use. An LPN performed a blood glucose check on a resident after hand hygiene and gloves, then returned to the nurse's office without cleaning or disinfecting the glucometer. The LPN stated she did not usually clean it unless there was blood on it or it was dirty. An admin nurse stated staff were expected to clean and disinfect glucometers after each use.
Incomplete Daily Nurse Staffing Sheets: The facility failed to post daily nurse staffing sheets with accurate, identifiable actual hours worked by licensed and unlicensed staff. Review of multiple staffing sheets showed only total hours for RN/LPN and CMA/CNA staff, and one day the sheet was not posted at all. An LN stated the 3 PM to 3 AM shift completed the sheet from the weekly schedule, while an Administrative Nurse said actual hours were not recorded at the end of each shift and were calculated later from agency invoices.
Unsafe and Poorly Maintained Resident and Common Areas
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment in resident rooms and common areas. During observations, multiple resident rooms had walls with missing paint and exposed sheetrock, and several bathroom doors and door frames had missing paint with exposed wood and exposed metal. Similar conditions were observed in the public bathroom, where the door had a large area of missing paint with exposed wood. During the facility walkthrough, surveyors observed numerous hallway ceiling tiles with brown water stains, breaking and flaking surfaces, and several tiles that were bulging and creating open access to the drop-ceiling space above. In the clean utility room, ceiling tiles around the A/C unit had water stains and were flaking and breaking, the wall molding by the countertop was pulling away from the wall, and the wall by the sink had a large scraped area with exposed sheetrock. A handrail in the Sunflower hallway also had a large scraped area with exposed wood. Administrative staff stated they were unaware of the ceiling tile, wall, and molding issues in the clean utility room and resident areas, and maintenance stated the issues had not been reported and that ceiling tiles were replaced on a spot-check basis as noticed.
Failure to Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform R18 or her representative about the risks and benefits of taking Buspar, an antianxiety medication. R18’s EMR documented diagnoses of Alzheimer’s disease, anxiety, psychotic disorder, and major depressive disorder. Her 07/09/25 MDS showed a BIMS score of 4, indicating severely impaired cognition, and documented that she took antipsychotic, antidepressant, antianxiety, and opioid medications. The Psychotropic Drug Use CAA identified Buspar as the antianxiety medication used for anxiety, and the care plan and physician’s orders documented Buspar three times daily for anxiety disorder. Review of the drug regimen reviews found no request for staff to obtain informed consent from the resident’s representative, and the clinical record lacked evidence of informed consent for Buspar. On 10/07/25, an LN stated that Administrative Nurse D obtained consents for psychotropic medications from the resident and/or representative. Later that day, Administrative Nurse E stated she could not find an informed consent for Buspar and confirmed it was not documented that Buspar was discussed with the resident or representative. On 10/08/25, Administrative Nurse D stated she obtained informed consent from the resident or representative but was unable to find the consent for R18’s Buspar and could not find a note that it was discussed.
Failure to Attempt GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident’s antipsychotic medication, Seroquel. The resident had diagnoses of Alzheimer’s disease, anxiety, psychotic disorder, and major depressive disorder. The 07/09/25 MDS documented a BIMS score of 4, indicating severely impaired cognition, and noted that the resident had no delusions or hallucinations, wandered one to three days during the seven days before the assessment, and was receiving an antipsychotic, antidepressant, antianxiety, and opioid medication. The MDS also documented that no GDR for the antipsychotic was attempted and that the physician had not documented that a GDR was contraindicated. The resident’s Psychotropic Drug Use CAA stated that Seroquel was used for depression and mania, while the care plan documented Seroquel at supper for anxiety and restlessness. Physician orders showed Seroquel 25 mg by mouth in the evening for psychotic disorder with delusions due to a known physiological condition, ordered on 05/11/24. Review of the resident’s drug regimen reviews showed no requests for a GDR for Seroquel. Staff interviews confirmed there was no request for a GDR, no attempt for a GDR, and no risk-versus-benefits statement for the medication, and the administrative nurse stated she was aware that GDRs are required unless contraindicated. The facility policy stated that residents prescribed an antipsychotic medication shall receive gradual dose reductions per CMS requirements.
Failure to Provide Written Transfer Notice, Ombudsman Copy, and Bed Hold Information
Penalty
Summary
The facility failed to provide Resident 6 with a written notification of transfer to the resident and/or the resident’s representative as soon as practicable and failed to send a copy of that notification to the ombudsman. Resident 6 had diagnoses of heart failure and dementia. On 09/07/25 at 07:57 AM, the resident was documented as short of breath when walking to the bathroom, with wheezing and diminished breath sounds. Later that morning, at 11:05 AM, the resident was documented as admitted to the hospital for observation, with the hospital planning to take fluid off. Resident 6’s EMR did not contain documentation of written notification explaining the reason for the transfer to the hospital, and it also lacked documentation that the bed hold was explained and given to the resident or the representative. A Licensed Nurse stated that Social Services provided the bed hold and that nurses verbally notified families of hospital transfers. Social Services stated she was the person who reviewed the bed hold with the resident’s representative but forgot to do it for Resident 6’s transfer and was unaware of the regulation to notify the resident in writing and notify the ombudsman. An Administrative Nurse stated the bed hold should be completed and signed by the next business day after transfer and said she was unaware of the regulation to notify the resident’s representative in writing of a discharge or transfer and that the facility had not been notifying the ombudsman.
Incomplete Baseline Care Plan for Resident with Dementia and Wandering Behavior
Penalty
Summary
The facility failed to complete a baseline care plan for R29 within the required timeframe after admission. R29’s EMR documented diagnoses of dementia, failure to thrive, HTN, and atrial fibrillation, and the admission MDS was not completed because the resident had not yet been admitted long enough for the 10/03/25 MDS. R29’s baseline care plan, dated 09/25/25, was unsigned by the resident or responsible party and documented that he was full code, but the fall risk section was not completed. The baseline care plan also documented wandering behavior, including a previous incident of wandering outside of the house, but the elopement section was not completed and did not address whether he had a WanderGuard. The Social Service portion was not completed, including discharge or long-term stay plans, and the care plan incorrectly indicated that he took an antipsychotic medication. During observation, R29 was seen in a wheelchair with a WanderGuard around his left ankle and later was observed lying diagonally on his bed with his feet hanging off the bed and his left foot on the mattress on the floor beside the bed. Staff stated that the baseline care plan is used to know how to care for a resident, and administrative nurses stated the charge nurse or ADON usually reviews it with the resident and/or representative, but R29’s representative left early on admission day and staff did not call or attempt to complete it another way. The facility policy stated it would ensure each resident has an individualized current care plan.
Failure to Disinfect Glucometer After Blood Glucose Check
Penalty
Summary
The facility failed to implement adequate and acceptable infection control practices when staff did not disinfect a glucometer after use. During observation on 10/07/25 at 11:22 AM, a Licensed Nurse performed a blood glucose check on Resident 2 after hand hygiene and donning gloves, then returned to the nurse's office without cleaning or disinfecting the glucometer. When interviewed shortly afterward, the nurse confirmed that she did not clean the glucometer and stated that she did not usually clean it unless there was blood on it or it was dirty. On 10/08/25, an Administrative Nurse stated that staff were educated yearly on measuring blood glucose using glucometers and that she expected staff to clean and disinfect the glucometers after each use. The facility's Infection Control for Living Center Residents policy stated that the infection control program was intended to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Incomplete Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information showing the actual hours worked by licensed and unlicensed staff. The facility had a census of 26 residents, and the sample included 12 residents. Review of daily staffing sheets for 08/01/25 through 08/07/25 showed that the sheets listed only total hours worked for nurses and CMA/CNA staff and did not list the actual hours worked. On 10/06/25 at 10:05 AM, the daily staffing sheet was not posted. On 10/07/25 at 10:11 AM, the staffing sheet was posted on the door frame of the nurse's office, but it still only listed total hours worked and did not include actual hours. At 10:26 AM, LN G stated that the 3 PM to 3 AM shift was responsible for completing the daily staffing sheets based on the weekly staffing schedule and taping the sheet to the nurse's office door frame. At 10:42 AM, Administrative Nurse A stated that the actual hours worked were not recorded at the end of each shift and that she calculated the actual hours for the daily staffing sheets after receiving agency invoices. The facility policy, St. [NAME] Living Center Staffing, dated 01/08/15, stated that the facility would designate a licensed nurse as charge nurse on each tour of duty and staff licensed personnel 24/7 using RNs and LPNs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Homes | 10.6 mi | ★★★★★ | 0 | 0 |
| Salem Home | 10.6 mi | ★★★★★ | 0 | 0 |
| Peabody Health And Rehab | 13.3 mi | ★★★★★ | 0 | 0 |
| Access Mental Health | 13.3 mi | — | 16 | 1 |
| Bethesda Home | 19.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Luke Living Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.