Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke Community Nursing Home during CMS and state inspections, most recent first.
Staff did not consistently use required safety straps during sit-to-stand lift transfers, resulting in a fall with major injury for a resident and placing others at risk. Additionally, a resident using a Broda chair for fall prevention was not regularly assessed, and necessary documentation such as physician orders and consents was missing, contrary to facility policy.
Surveyors found that the facility did not consistently label or date food items in the kitchen and dining areas, with many opened and unopened products missing complete dates or expiration information. Staff interviews revealed confusion and inconsistent practices regarding food labeling, and the facility was unable to provide a comprehensive policy on food storage and labeling. These deficiencies affected all residents receiving food services.
The facility did not maintain proper documentation or processes for its QAPI program, including failure to conduct root-cause analyses, develop specific interventions, or set measurable goals for quality improvement. In one case, a resident suffered a fall from a sit-to-stand lift resulting in a fractured arm, and the incident was not promptly reported or thoroughly investigated. Staff were unable to explain or provide documentation of systematic approaches for addressing such issues or monitoring improvement outcomes.
Staff did not consistently change gloves or perform hand hygiene when moving between contaminated and clean tasks during ADL care for two residents, and failed to clean gait belts between uses on multiple residents. Additionally, clean and dirty linens and equipment were stored together in shower rooms, and both shower and laundry areas had uncleanable surfaces due to damage, contributing to unsanitary conditions.
Staff were observed crushing and administering medications labeled 'DO NOT CRUSH' to two residents, resulting in a medication error rate of 10%. Multiple staff members prepared and gave these medications in crushed form without verifying appropriate orders or adhering to label instructions, and interviews revealed a lack of awareness of proper procedures and facility policy requirements.
A resident with PTSD and social phobia experienced discomfort and anxiety due to a video camera placed in her room for safety monitoring. Despite her repeated requests and those of her family to remove the camera, the facility required the camera to remain unless the resident agreed to keep her door open at all times, which she found distressing due to noise. The facility's actions did not align with its policy to respect resident privacy.
Failure to Use Safety Straps During Transfers and Inadequate Assessment of Broda Chair Use
Penalty
Summary
Staff failed to utilize required safety straps during transfers with sit-to-stand mechanical lifts for multiple residents, resulting in a fall with major injury for one resident and placing others at risk for falls. Observations revealed that during several transfers, staff did not use knee or chest safety straps as specified in both facility policy and the lift manufacturer's instructions. Staff interviews confirmed that safety straps were only used based on perceived need rather than as a standard precaution, and some staff were unaware of the requirement to use them consistently. One resident experienced a fall from the lift, which was not reported immediately, and the subsequent post-fall investigation was incomplete and delayed, lacking a root cause analysis. Additionally, the facility failed to ensure ongoing assessment and monitoring for a resident using a Broda chair as a fall prevention measure. The resident was observed consistently in the Broda chair, and interviews with staff and family indicated concerns about the resident's loss of mobility and lack of reassessment for alternative seating options. Staff acknowledged that there were no current physician orders, consents, or quarterly assessments for the use of the Broda chair, despite facility policy requiring these elements. Documentation supporting the use of the Broda chair as a restraint was not provided upon request. Facility policies reviewed during the survey required the use of safety straps during mechanical lift transfers and mandated thorough post-fall investigations, including root cause analysis. Policies also required regular assessment, physician orders, and consent for Broda chair use. These requirements were not followed, as evidenced by staff practices, incomplete documentation, and lack of timely reporting and investigation of incidents.
Failure to Properly Label and Date Food Items in Kitchen and Dining Areas
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen and dining areas, as observed during a survey. Multiple opened and unopened food items, including blueberries, pickled relish, pepperoni, ricotta cheese, Caesar dressing, sour cream, hashbrowns, honey, sugar free icing, vinegar, pasta, spices, food dyes, and sauces, were found with incomplete, missing, or expired labels. Some items lacked the year on the date, while others had no date at all. Staff interviews revealed inconsistent understanding and application of food labeling policies, with some staff stating they used general timeframes for all items and others admitting to not keeping up with labeling, especially for spices. There was also a lack of accessible use-by date charts in the kitchen for staff reference. Further review showed that the facility did not have a comprehensive policy and procedure regarding food storage and labeling, as requested documentation was not provided in full by the end of the survey. The partial policy presented referenced general guidelines for dry pasta and refrigerated foods but did not cover all aspects of food storage and labeling. These deficiencies affected all residents receiving food services from the facility, as the improper labeling and lack of clear procedures placed them at risk for consuming expired or contaminated food.
Failure to Document and Implement Effective QAPI Processes and Root-Cause Analysis
Penalty
Summary
The facility failed to maintain adequate documentation of its ongoing Quality Assurance and Performance Improvement (QAPI) program, specifically lacking evidence of how contributing causes of problems were determined and how root-cause analyses were conducted for identified issues. The facility also did not establish corrective action plans with specific interventions or measurable outcomes for set goals, nor did it document processes for monitoring and revising performance improvement projects to ensure goals were met. These deficiencies were observed in the facility's QAPI documentation and through staff interviews, which revealed an absence of clear processes for root-cause analysis, intervention development, and outcome measurement. A specific incident involved a resident who experienced a fall from a sit-to-stand lift, resulting in a fractured arm. The post-fall huddle investigation form for this incident was not completed until the day after the fall, as the CNAs involved did not report the incident to the nurse on duty in a timely manner. The form was incomplete and did not reflect that a root-cause analysis had been performed. Staff interviews confirmed that no immediate huddle or root-cause determination took place following the incident. Further review of the facility's QAPI plan and related policies showed a lack of documentation regarding the processes for identifying root causes, developing interventions, setting measurable and time-bound goals, and monitoring project outcomes. Staff were unable to explain or provide evidence of systematic approaches for addressing problem-prone areas or ensuring the effectiveness of performance improvement activities, as required by the facility's own policies.
Infection Control Lapses in Hand Hygiene, Equipment Cleaning, and Environmental Maintenance
Penalty
Summary
Staff failed to adhere to proper infection prevention and control practices during the provision of activities of daily living (ADL) care for multiple residents. Specifically, staff members did not change gloves or perform hand hygiene when transitioning from contaminated tasks, such as cleaning residents after bowel movements, to clean tasks, such as applying clean briefs or handling clean supplies. Observations included staff touching their faces with soiled gloves, retrieving clean items with contaminated gloves, and failing to perform hand hygiene after glove removal. Interviews confirmed that staff were aware of the expectations for glove changes and hand hygiene, but these practices were not consistently followed. Additionally, the facility was unable to provide a policy specific to hand hygiene upon request. Gait belt disinfection practices were also deficient. Staff used the same gait belt on multiple residents throughout the day and only sanitized the belts at the end of their shifts, rather than after each use. The facility did not have a written policy regarding the cleaning of gait belts, although staff expressed an expectation that belts should be cleaned after every use. This practice was observed during resident transfers and ambulation assistance. Environmental concerns were identified in the shower and laundry rooms. Dirty linen and trash bins were stored in the same areas as clean equipment and supplies, and clean linens were kept in close proximity to soiled items. The shower rooms and laundry areas had uncleanable surfaces due to cracked flooring, broken tiles, chipped countertops, and damaged walls. Staff acknowledged the inappropriate storage practices and the poor condition of these areas, noting that a remodel was planned but not yet completed. The presence of strong odors and infrequent cleaning further contributed to the unsanitary conditions.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 10% based on 3 errors out of 30 observed medication administrations. Staff were observed crushing and administering medications that were specifically labeled as 'DO NOT CRUSH OR CHEW, TAKE WHOLE,' including gabapentin and tamsulosin, to two residents. These actions were performed by multiple staff members on separate occasions, with the medications being mixed into pudding and given to the residents. The medication packaging clearly indicated that these medications should not be crushed, yet this instruction was not followed. Interviews with staff revealed a lack of awareness regarding the proper administration of these medications and the absence of orders permitting the medications to be crushed. One staff member indicated that the practice of crushing these medications had been ongoing and assumed that the pharmacy and physician were aware, but could not confirm the existence of appropriate orders. Another staff member acknowledged that the facility did not obtain specific orders for crushing medications and was unaware of the labeling instructions. The facility's own medication administration policy required staff to check medication labels and administer drugs by the method ordered, but these procedures were not followed in the observed cases.
Failure to Respect Resident Privacy Due to Video Monitoring
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records by placing a video camera in the resident's room without adequately respecting her wishes for privacy. The camera was positioned on the resident's desk, facing her as she sat on her bed, and the resident expressed discomfort, stating that she sometimes forgot the camera was there, particularly when dressing. The resident, who has a history of PTSD and social phobia, reported increased anxiety and a feeling of being imprisoned due to the camera's presence. She indicated that she wanted to be alone and preferred her door closed to reduce noise, but was told by the facility that if the camera was removed, her door would have to remain open at all times. Staff interviews confirmed that the camera was intended for safety due to concerns about the resident performing unsafe actions and falling, despite the resident not having dementia and being able to call for help independently. The resident and her family member repeatedly requested the removal of the camera during care plan meetings, but were told the only alternative was to keep the door open, which exacerbated the resident's anxiety. The facility's own policy states that video monitoring should not violate residents' right to privacy, yet the resident's requests were not honored, leading to her feeling controlled and her privacy not being respected.
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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 Ronan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Polson Health & Rehabilitation Center | 9.8 mi | — | 6 | 0 |
| Hot Springs Health & Rehabilitation Center | 25.6 mi | — | 8 | 0 |
| Clark Fork Valley Nursing Home | 35.4 mi | — | 2 | 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.