St Luke Lutheran Nursing Home
1301 Saint Luke Drive, Spencer, IA 51301 · Clay County · 79 certified beds · avg 73 residents/day · certified since Jul 7, 2003
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 4, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 22, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 5, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 4, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 22, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | D |
| 2024 | 11 | 1 | J ▲ |
| 2025 | 9 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $90,076, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 4, 2025 | Fine | $81,679 |
| Aug 22, 2024 | Fine | $8,397 |
| Aug 22, 2024 | Payment Denial | 21 days from Sep 20, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.62 | 4.37 | 3.95 | top 35% in Iowa; top 20% in the U.S. |
| Registered Nurse hours | 1.06 | 0.85 | 0.69 | top 22% in Iowa; top 13% in the U.S. |
| Weekend total nurse staffing | 4.28 | 3.86 | 3.50 | top 25% in Iowa; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.65 | 0.51 | 0.48 | top 20% in Iowa; top 20% in the U.S. |
| Total nursing staff turnover (%) | 44.1 | 44.0 | 45.8 | bottom 44% in Iowa; top 48% in the U.S. |
| RN turnover (%) | 21.4 | 42.1 | 42.9 | top 23% in Iowa; top 16% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.71, RN 0.85, weekend 3.44. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| BCG Holdings INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Brighton Consulting Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Cattail BCG LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Cattail INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Chindlund, Katie | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/22/2018 |
| Clausen, Jerry | Individual | Corporate Director | NOT APPLICABLE | 03/01/2015 |
| Ecsi INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| GCS Tech INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Halverson, Gary | Individual | Corporate Director | NOT APPLICABLE | 03/01/2017 |
| Hoye, David | Individual | Corporate Director | NOT APPLICABLE | 04/04/2023 |
| Hughes, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/28/1992 |
| Hunziker, Kenneth | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/19/2010 |
| Hunziker, Kenneth | Individual | ADP of the SNF | NOT APPLICABLE | 10/02/2025 |
| Iowa Health Care Association | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Jacobsen, Jenna | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Kading, Doug | Individual | Corporate Director | NOT APPLICABLE | 04/04/2023 |
| Klein, Amanda | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2010 |
| Koenecke, Mike | Individual | Corporate Director | NOT APPLICABLE | 04/04/2023 |
| Kruse, Jane | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2018 |
| Mechler, Deborah | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What training do all staff get on dementia care and on spotting and reporting abuse?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Spencer Post Acute Rehabilitation Center | 2.2 mi | Spencer, IA | ★☆☆☆☆ | 1/5 | |
| Ruthven Community Care Center | 11.5 mi | Ruthven, IA | ★★★★☆ | 4/5 | |
| Accura Healthcare of Milford | 14.2 mi | Milford, IA | ★★★★☆ | 5/5 | |
| Community Memorial Health Center | 18.5 mi | Hartley, IA | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165484.