Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke's Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with CHF and CKD 3b had a major decline after a fall with a closed hip fx and surgical repair. The resident went from needing partial to moderate assist with transfers and limited ambulation to requiring a Hoyer lift, maximal assist with eating and transfers, no longer ambulating, and being incontinent of bowel and bladder, but the facility did not complete a comprehensive Significant Change in Status Assessment; the RNAC confirmed the omission.
The facility failed to consistently carry out individualized pressure injury prevention measures for two residents with significant vascular and skin issues. One resident with PVD, CHF, diabetes, and critical limb ischemia had a low air loss mattress ordered, but staff did not adjust the mattress to the resident’s documented weight and only checked that it was functioning. Another resident with PVD, generalized weakness, and multiple arterial/traumatic wounds had a wound nurse recommendation for an alternating air mattress, but observations showed no alternating air mattress in place, and the DON confirmed it was not being used because of the cupped mattress.
A resident with respiratory failure and CHF was observed receiving oxygen at 2 L/min via nasal cannula, despite a physician order and care plan specifying 3 L/min. The DON confirmed the resident was not receiving the ordered oxygen flow rate, in violation of facility policy and state regulations.
A resident receiving comfort care with orders for Morphine Sulfate had doses signed out on the controlled substance record, but there was no matching documentation in the MAR to indicate administration. This discrepancy in narcotic documentation was confirmed by the DON and represents a failure to follow facility policy for controlled medication accountability.
A facility failed to update the discharge plan for a resident with dementia, who had a BIMS score indicating moderate cognitive impairment. Initially, the discharge plan aimed for community discharge, but a social service note later identified the resident as a long-term placement. No updates were made to the discharge plan to reflect this change, as confirmed by the DON.
A resident with diabetes and dementia developed a new Stage IV sacrum pressure injury after the facility discontinued the use of a P-500 mattress, which was initially helping to prevent pressure injuries. The resident's condition worsened following the mattress change, leading to the development of a new pressure sore.
A resident, who was cognitively intact and had conditions including congestive heart failure, fell from a transport van due to the vehicle operator's failure to secure the lift properly. The resident sustained bruising and mild pain but no major injuries. The incident highlights a lapse in safety measures by the contracted transportation company.
The facility failed to create individualized care plans for two residents with dementia, resulting in unmanaged behavioral symptoms. One resident exhibited aggressive behavior, while another showed increasing agitation and refusal of care. Both care plans lacked specific interventions based on the residents' preferences and histories.
A facility failed to document a clinical rationale for the extended use of an as-needed psychotropic medication for a resident with dementia and anxiety disorder. The resident received Lorazepam on three occasions over three months without justification for its use beyond 14 days, as confirmed by the DON.
Failure to Complete Significant Change in Status Assessment After Major Decline
Penalty
Summary
The facility failed to complete a comprehensive Significant Change in Status Assessment using the MDS after Resident 50 experienced a major decline in physical functioning. The resident was admitted with chronic diastolic heart failure and CKD stage 3b, and the admission MDS documented moderate cognitive impairment with a BIMS score of 10, set-up assistance for eating, partial to moderate assistance with transfers, ambulation up to 10 feet with partial to moderate assistance, frequent bladder incontinence, and occasional bowel incontinence. After a fall that resulted in a closed left hip fracture and hospital transfer, the resident returned to the facility following surgical repair. Physician orders then directed use of a Hoyer lift for transfers and a Broda chair when out of bed. The quarterly MDS documented further decline, including a BIMS score of 9, maximal assistance with eating and transfers, no longer ambulatory status, and total incontinence of bladder and bowel. The clinical record contained no documentation that the facility completed a comprehensive Significant Change in Status Assessment despite the resident’s decline affecting mobility, transfers, eating ability, continence, and functional independence, and the RNAC confirmed the assessment was not completed.
Failure to implement ordered pressure redistribution interventions
Penalty
Summary
The facility failed to consistently implement individualized pressure injury prevention interventions for two residents with significant skin and circulation-related conditions. Facility policy required pressure injury prevention measures to be individualized based on each resident’s risk factors, clinical condition, and physician orders, and the mattress manufacturer’s instructions directed staff to use the resident’s weight setting as a guide for proper pressure adjustment. The report also cited NPIAP guidance that support surfaces should be selected according to the resident’s clinical condition, weight, size, and pressure injury risk. One resident had diagnoses including peripheral vascular disease, chronic heart failure, and diabetes, and was admitted to Hospice for critical limb ischemia of the right lower extremity. A physician order dated April 30, 2026, specified a low air loss mattress with function checks every shift. The resident weighed 202.6 pounds on June 6, 2026, but an observation on June 24, 2026, found the mattress set at approximately 320 pounds rather than the documented weight. Staff stated they checked the mattress each shift to ensure it was functioning but did not verify or adjust the therapeutic weight setting, and the hospice RN confirmed the mattress was not adjusted to the resident’s weight. A second resident had peripheral vascular disease and generalized muscle weakness, was cognitively intact, and had a care plan for potential and actual skin impairment with a history of pressure, traumatic, and arterial wounds. An outside wound care nurse noted multiple wounds on the left foot, ankle, heel, knee, shin, toes, and right elbow and recommended an alternating air mattress for pressure reduction with function checks every shift, in addition to a cupped mattress for fall prevention. However, observations on June 23 and June 24, 2026, showed no alternating air mattress attached to the bed, and there was no physician order for one during the survey period. The DON confirmed the resident did not have an alternating air mattress because of the cupped mattress used to help prevent falls.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for one resident. According to the clinical record, the resident was admitted with diagnoses including respiratory failure and congestive heart failure, and had a physician's order for continuous oxygen therapy via nasal cannula at 3 liters per minute. The resident's care plan also specified oxygen therapy at this rate, consistent with the physician's order and the facility's policy, which requires oxygen to be administered per physician instructions. Despite these orders, observations on multiple occasions showed the resident receiving oxygen at only 2 liters per minute. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident was not receiving the ordered amount of oxygen. The failure to administer oxygen at the prescribed rate constituted a violation of both the facility's policy and state regulations.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for one resident. According to facility policy, all controlled substances must be recorded on a designated usage form, and the dosage recorded must match the documentation in the Medication Administration Record (MAR) and be retained in the resident's medical record. For a resident admitted with diagnoses including vascular dementia, COPD, osteoporosis, and cerebral infarction, physician orders included Level 4 Comfort Care and administration of Morphine Sulfate Solution as needed for pain. The controlled substance record showed that nursing staff signed out doses of morphine on three occasions. However, there was no corresponding documentation in the MAR indicating that the medication was administered to the resident at those times. This discrepancy between the controlled substance record and the MAR demonstrates a failure to ensure accurate documentation and reconciliation of narcotic records, as required by facility policy. The Director of Nursing confirmed these discrepancies during an interview.
Failure to Update Discharge Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for Resident 25, who was admitted with a diagnosis of dementia and had a BIMS score indicating moderate cognitive impairment. Upon admission, a discharge plan was created with the goal of discharging the resident to the community. However, a social service progress note later indicated that the resident was a long-term placement, and no updates or revisions were made to the discharge plan to reflect this change. During an interview, the Director of Nursing confirmed the absence of documented evidence of an updated discharge care plan that aligned with the resident's goal to return to the community.
Discontinuation of P-500 Mattress Leads to New Stage IV Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent the development of pressure sores. The resident, who was admitted with diabetes, dementia, and multiple pressure injuries, including a Stage IV sacrum injury, initially had a healed sacrum pressure injury as of April 13, 2023. The resident was using a P-500 mattress, a specialized therapy bed surface designed to prevent and treat pressure injuries. However, the use of this mattress was discontinued on February 9, 2024, and replaced with an alternating air mattress on February 8, 2024. Following the discontinuation of the P-500 mattress, the resident developed a new open pressure injury on the sacrum by February 24, 2024, which progressed to a Stage IV pressure injury. The facility's failure to continue using the P-500 mattress, as recommended by a wound care note, contributed to the development of this new pressure injury. The Nursing Home Administrator confirmed that the discontinuation of the P-500 mattress was a factor in the resident's new Stage IV sacrum pressure injury.
Failure to Implement Safety Measures Leads to Resident Fall
Penalty
Summary
The facility failed to implement effective safety measures to prevent a fall for one resident, identified as Resident 9. This resident, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including congestive heart failure and chronic kidney disease. On a specific date, Resident 9 fell from a transport van while returning from a podiatry appointment. The incident occurred because the vehicle operator, an employee of a contracted transportation company, pushed the resident out of the vehicle without ensuring the lift chair was properly positioned on the ground, leading to the resident falling and hitting the ground. Following the fall, Resident 9 was sent to the emergency department for assessment and returned to the facility in stable condition. The resident experienced mild generalized aches and had bruising on her left upper buttock and left lateral thigh. Despite the fall, no fractures were noted, and the resident denied significant pain. The facility's Nursing Home Administrator confirmed that the vehicle operator failed to follow appropriate safety measures, which resulted in the resident's fall and subsequent injuries.
Failure to Implement Individualized Care Plans for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement effective individualized person-centered care plans for two residents diagnosed with dementia, leading to unmanaged behavioral symptoms. Resident 12, admitted with unspecified dementia and generalized anxiety disorder, exhibited verbally aggressive and argumentative behavior, including yelling, cursing, and throwing items. Despite these behaviors being documented, the resident's care plan did not include specific interventions tailored to address these behaviors, nor did it consider the resident's preferences, social history, or customary routines. Similarly, Resident 19, also diagnosed with unspecified dementia, displayed increasing behavioral issues such as yelling, crying, agitation, and refusal of care. The resident's care plan similarly lacked individualized interventions to manage these behaviors, failing to incorporate an assessment of the resident's preferences and history. An interview with the Nursing Home Administrator confirmed the absence of evidence for the development and implementation of person-centered plans to address these dementia-related behaviors.
Lack of Clinical Rationale for Extended Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not providing a clinical rationale for the continued use of an as-needed psychotropic medication. Resident 12, who was admitted with diagnoses of unspecified dementia and generalized anxiety disorder, had a physician's order for Lorazepam, an antianxiety medication, to be administered as needed every 8 hours for anxiety or shortness of breath. The medication was administered on three separate occasions over a period of three months, but there was no documented clinical rationale for its extended use beyond 14 days. The Director of Nursing confirmed that there was no physician documentation justifying the continued as-needed use of Lorazepam for more than 14 days. This lack of documentation indicates a failure to comply with regulations requiring a clinical rationale for the extended use of psychotropic medications, potentially leading to the resident being subjected to unnecessary medication without proper justification.
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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.
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Nursing homes near Coaldale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenwood Center For Nursing And Rehab | 2.7 mi | ★★★★★ | 19 | 1 |
| Mahoning Operating Llc | 7.8 mi | ★★★★★ | 12 | 0 |
| Manor At St Luke Village,the | 8.6 mi | ★★★★★ | 16 | 0 |
| Pavilion At St Luke Village, The | 8.7 mi | ★★★★★ | 0 | 0 |
| Forest Hills Rehabilitation & Healthcare Center | 9.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.