Luther Home

Inspectors wroteBased on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 1 of 8 staff reviewed for caregiver background checks. The facility did not have completed Department of Justice (DOJ) or Government Findings Reports for Certified Nursing Assistant (CNA)-E.

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 5 sampled residents. On 6/20/26, the facility was informed of an allegation of abuse involving R1. The allegation of abuse was not reported to the SA.

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 5 sampled residents. On 6/20/26, the facility was informed of an allegation of abuse involving R1. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure the comprehensive care plan contained pertinent hospital discharge instructions for 1 resident (R) (R1) of 5 sampled residents. R1's hospital discharge summary contained instructions to sit for a maximum of one hour while up in their wheelchair for a maximum of 2-3 hours total per day. R1's care plan did not contain the instructions.

Inspectors wroteBased on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for 1 resident (R) (R4) of 4 residents in a total sample of 8 residents. Staff witnessed Certified Nursing Assistant (CNA)2 be verbally abusive to R4.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 residents (R) of the 61 residents residing in the facility. The facility did not ensure transmission-based precautions (TBP) were implemented for R53 for Norovirus (The most common cause of gastroenteritis, characterized by non-bloody diarrhea, vomiting, and stomach pain. The virus is highly contagious and spread through contaminated food or water or person-to-person contact, contaminated surfaces, or through air from the vomit of an infected person.) Licensed Practical Nurse (LPN)-K did not complete appropriate hand hygiene during medication administration. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R8) of 1 sampled resident with a Guardian was protectively placed at the facility. R8 had a legal Guardian at the time of admission on [DATE]. R8's medical record included an order for Guardianship of person and estate dated 9/21/22. R8's medial record did not contain an order for protective placement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R2 and R22) of 2 sampled residents were provided a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which is used to inform residents of the potential liability for payment (daily cost of care and services at the facility). The facility did not provide an ABN form to R2 when R2's Medicare Part A benefits ended on 10/10/25 and R2 remained in the facility. The facility did not provide an ABN form to R22 and when R22's Medicare Part A benefits ended on 11/25/25 and R22 remained in the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free from abuse. The facility was aware of verbal abuse directed at R2 by R2's activated Power of Attorney for Healthcare (POAHC) on 10/16/25. An investigation was not completed and the facility did not implement measures to protect R2 from future abuse. A second occurrence of verbal abuse directed at R2 by POAHC-M occurred on 12/8/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility was informed of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility became aware of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not provide Preadmission Screening and Resident Review (PASRR) services for 1 resident (R) (R8) of 24 sampled residents. The facility did not contact the state mental health authority to pursue PASRR Level I or II screening for R8 who had a mental illness diagnosis.

Inspectors wroteBased on staff interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice for 1 resident (R) (R1) of 22 sampled residents. The facility did not accurately document and treat R1's injured right ankle after R1 was lowered to the ground on 11/16/25.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R41) of 22 sampled residents. The facility did not ensure R41's Average Volume Assured Pressure Support (AVAPS) machine was in working condition and did not follow orders to apply R41's AVAPS machine while sleeping.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R25 and R41) of 22 sampled residents. Medications were observed on a table in R25's room. R25 did not have a self-administration of medication assessment that indicated R25 could safely and accurately self-administer medication. In addition, R25 did not have physician orders for the medications. Medications were observed on R41's counter. R41 did not have a self-administration of medication assessment that indicated R41 could safely and accurately self-administer all of the medications. In addition, R41 did not have a physician order for 1 of the medications.

Inspectors wroteBased on family representative interview, staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) about an allegation of abuse for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. Staff did not notify R1's POAHC of the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 (Licensed Practical Nurse (LPN)-D) of 1 contracted staff reviewed for a caregiver background check. The facility did not ensure a thorough and timely caregiver background check was completed for LPN-D.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. LPN-D was not provided abuse education prior to returning to resident care on 9/13/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored in a sanitary manner. This practice had the potential to affect multiple residents residing in the facility. Kitchen equipment and food storage areas were not in a clean and sanitary condition.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R31, R30, and R32) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R31 was transferred to the hospital on 1/16/24 and 6/5/24. R31, R31's representative, and the Ombudsman were not provided with written notice of the transfers. R30 was transferred to the hospital on 6/8/24. R30, R30's representative, and the Ombudsmen were not provided with written notice of the transfer. R32 was transferred to the hospital on 8/19/24. R32, R32's representative, and the Ombudsmen were not provided with written notice of the transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R31) of 3 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R31 was transferred to the hospital on 1/16/24 and 6/5/24. R31 and/or R31's representative were not provided with a bed hold notification.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmission of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 Resident (R) (R34) of 14 sampled residents. R34's Quarterly MDS assessment was completed on 6/13/24. The assessment was electronically submitted on 8/21/24 which was 55 days late and not within the 14-day required timeframe.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an investigation regarding potential misappropriation of property for 1 Resident (R) (R2) of 1 resident contained documentation that indicated a thorough investigation was completed. On 9/30/23, the facility submitted an initial report to the State Agency (SA) regarding potential misappropriation of tramadol (a controlled substance and narcotic medication used to treat moderate to severe pain) prescribed to R2. On 10/6/23, the facility submitted the findings of their investigation. The investigation did not contain documentation that indicated a thorough investigation was completed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent or contain the transmission of communicable diseases and infection, including COVID-19. This had the potential to affect all 63 residents residing in the facility. The facility did not ensure staff performed proper hand hygiene during the provision of cares for 4 Residents (R) (R7, R8, R11, and R13) of 4 residents. The facility did not ensure staff wore eye protection in rooms of residents who were on isolation precautions related to COVID-19. The facility did not ensure staff wore an N95 respirator in a resident's room who was on isolation precautions related to COVID-19. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate treatment and services to prevent a urinary tract infection (UTI) for 1 Resident (R) (R7) of 4 sampled residents. R7 was not provided perineal cleansing after an episode of urinary incontinence.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was served under sanitary conditions. This had the potential to affect multiple residents. Items located in the kitchen and kitchenettes were not properly dated, were past the manufacturer's best-by date and did not contain resident names.

Inspectors wroteBased on staff interview, and record review, the facility did not notify a physician of a change in condition for 1 Resident (R) (R60) of 21 sampled residents. R60's physician was not notified of R60's change of condition on [DATE].

Inspectors wroteBased on staff interview, and record review, the facility did not ensure 1 Resident (R) (R45) of 18 sampled residents met the PASRR (Pre-admission Screen and Resident Review) requirements. R45's Level I PASRR screen was marked yes for a 30-day exemption; however, R45 remained in the facility beyond the 30 days without a Level II PASRR screen.

Inspectors wroteBased on staff interview, and record review, the facility did not obtain weights as part of nutritional monitoring for 1 Resident (R) (R50) of 1 resident reviewed for tube feeding. R50's admission orders included an order for daily weights. The facility's policy was to obtain weekly weights. Staff obtained two weights for R50 from 5/12/23 through 6/7/23.