Luther Manor Retirement & Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oversight and prevent injury for two residents (Resident #1 and Resident #44) in a sample of 23 residents. Resident #1 was dependent on staff for transfers. When his/her electronic bed did not function properly, staff manually transferred the resident and caused a laceration to the resident's leg, which required emergency medical care, including sutures, antibiotic use to prevent infection, pain management medication, wound care and wound clinic appointments. Resident #44 had a history of falls and wandering and staff failed to provide oversight, resulting in an elopement that resulted in a fall with injury. The facility census was 55. The administrator was notified of a past noncompliance on 11/06/25, for Resident #44 which occurred on 08/28/25. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to store, prepare, and serve food in a safe and sanitary manner. Staff failed to ensure the temperature of a refrigerator used to store resident food was maintained at or below 45 degrees Fahrenheit (F) and the freezer was maintained at or below 0 degrees F. Staff failed to ensure food was discarded when it showed signs of deterioration. Staff did not practice proper handwashing, glove hygiene or hair restraint usage when preparing and serving food in the kitchen. Staff failed to ensure the facility's ice machine was clean and sanitary. The facility census was 55. The facility did not provide policies for food storage, dietary handwashing/gloving, hair restraints, ice machine cleaning, or storing resident food items. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) buy using gowns and gloves during high-contact resident care activities) and properly handle dirty linens for two residents (Resident #1 and #6) in a review of 23 sampled residents. Additionally, the facility failed to complete a required Legionella (a type of bacteria found in [NAME] that cased Legionnaires' disease, a severe form of pneumonia, when inhaled in water droplets or mist) program. The facility census was 55. Review of the facility policy, EBP Policy and Procedure, revised 08/05/25, showed the following: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility census was 55. The facility was not able to provide a policy regarding required in-service training for Nursing Assistants upon request. Review of the facility assessment, dated 05/01/23, showed the following: -Staff competencies and annual training requirements per regulatory authority and/or facility policy: 1. Abuse, neglect, exploitation and misappropriation;2. Advanced directives;3. Behavioral health;4. Communication;5. Compliance and ethics;6. Cardiopulmonary resuscitation;7. Dementia care management;8. Equipment and assistive device training;9. Infection Control;10. -Other areas identified as areas of weakness during annual performance review/competency evaluation;11. Promoting resident's independence;12. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain individual resident ledgers for two residents (Resident #3 and #34) of two residents the facility held funds for, failed to send quarterly statements to the resident or the resident's representative and failed to distribute the accrued interest in the resident trust fund between the residents' accounts. The facility census was 55. Review of the facility policy, Personal Funds Policy and Procedures, updated 11/11/24, showed the following:-Upon written authorization of a resident, a resident may deposit personal funds for safekeeping with the facility if they so desire. Each resident will have their own personal ledger accounting of all transactions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff indicated in the resident's medical record their wishes for Cardiopulmonary Resuscitation (CPR - an emergency life-saving procedure for someone whose breathing or heartbeat has stopped) and documented the residents' choice of code status in such a way to be readily accessible to staff in the event of an emergency. This affected five residents (Resident #1, #18, #19, #60 and #61) in a sample of 23 residents. The facility census was 55. Review of the undated facility policy, Full Code vs. Do Not Resuscitate (DNR) Protocol, showed the following:-Upon finding a resident with an absence of pulse and respirations, the first actions should be to notify a nurse and determine the resident's code status;-The code status was in the Electronic Medical Record (EMR); [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required background screenings including the criminal background check (CBC) and employee disqualification list (EDL) checks, prior to employment for four of ten newly hired employees (Administrator, Housekeeper M, Registered Nurse (RN) JJ and Activity Assistant KK) who were hired since the last annual survey. The facility policy failed to address the Nurse Aide (NA) registry check as part of employment screening. The facility failed to complete the NA Registry check for five of ten employees (Administrator, Maintenance/Driver DD, Dietary [NAME] EE, Certified Nursing Assistant (CNA) GG and Caregiver II). The facility census was 55. Review of the undated facility policy, Employment Procedures, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with a palatable meal served at appetizing temperatures. The facility census was 55. 1. During an interview on 09/29/25 at 2:35 P.M., Resident #34 said the following:-He/She normally ate his/her dinner in his/her room;-The meal was cold by the time staff served him/her in his/her room. During an interview on 09/29/25, at 2:09 P.M., Resident #52 said the following:-Some evenings he/she ate in his/her room;-The food was warm, but did not taste good at all. During the resident council meeting on 09/30/25 at 1:10 P.M., several residents in attendance said their food was cold at dinner when served as a room tray. 2. Review of the facility's Resident Diet Orders, printed 9/30/25, showed the following: -Forty-seven residents with a physician-ordered regular diet; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 55. Review of the undated facility policy, Quality Assurance Performance Improvement (QAPI) Plan, showed the following: -Purpose statement: The purpose of QAPI is the organization is to take a proactive approach in improving the way the facility cares for and engages with residents, caregivers and other partners. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinent care consistent with acceptable standards of practice to prevent urinary tract infections (UTI) and failed to follow proper infection control procedures for one sampled resident (Resident #46). The facility census was 55. Review of the undated facility policy, Policy for Performing Catheter Care with Peri Care, showed the following: -Check catheter (flexible tube inserted into the bladder to drain urine) and drainage bag for leaks, kinks, level of bag, color and character of the urine, and make sure bedside drainage bag is attached to the frame of the bed;-Make sure catheter is secure, coiled and draining properly. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to three residents (#1, #2 and #3) or the representatives, in a sample of 23 residents reviewed that include the required information: reason for discharge/transfer, location being discharged /transferred to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to update and document a facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The facility census was 55. Review of the facility's Daily Census Report, dated 09/29/25, showed the facility census was 55. Review of the facility provided, facility assessment, showed the following:-The updated facility assessment of 10/01/25 only included page one that had the facility contact information and facility licensing information;-The remaining facility assessment for review was from 05/01/23 that listed information relating to residents for that date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and implement fall interventions to prevent falls for one resident (Resident #1), in a review of five sampled residents. On 07/06/25, staff failed to implement all interventions to prevent falls, including wedge cushions, while the resident was in bed. The resident rolled out of bed which resulted in a fracture of the tibia (a break of the larger of the two bones in the lower leg). The facility census was 55. Review of the facility's Fall Policy, dated 11/14/18, showed the following:-Purpose was to prevent a fall from occurring by identifying conditions and risk factors that typically lead to a fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's (Resident #2) physician timely of hip pain following a fall on 05/21/25. The resident complained of hip pain and received pain medication twice on 05/21/25, however, staff did not notify the physician of the resident's pain at the time of the fall until 05/23/25. An x-ray on 05/24/25 showed the resident fractured his/her hip. The facility census was 54. Review of the facility's protocol and procedure regarding nursing assessments, dated July 2012 showed the following: -It was the responsibility of every licensed and registered nurse to perform thorough nursing assessments on residents; -The nurse would notify the physician with any abnormal findings and/or complaints making sure the total assessment was performed and communicated with the physician. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the state survey agency for one resident (Resident #1), who suffered a fractured humeral shaft (new fracture), in a review of five sampled residents. The facility census was 56. Review of the facility's undated policy, Abuse Prevention Program, showed the following: -Facility management shall promptly and thoroughly investigate all reports of resident abuse, neglect and injuries of unknown source; -Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee, will immediately send validated report to the Department of Health and Senior Services, local police or licensing agencies; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust and debris. Staff failed to ensure the facility's ice machine was clean, ice scoops were stored in a clean container, and the ice machine drain contained an air gap. The facility census was 52. (The facility was unable to provide a kitchen/dietary policy, food safety requirement policy, or food preparation guidelines policy). 1. Observations on 10/17/23 from 9:35 A.M. to 5:30 P.M., in the kitchen, showed the following: -A moderate buildup of dust and debris on the walk-in cooler fan cover; -A moderate buildup of grease, dust and debris on the top, front, and sides of the oven, with buildup of grease and liquid runs on the inside front glass, doors, and sides of the oven; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed when staff failed to wash their hands when they removed contaminated gloves while performing post-incontinence care for two resident (Resident #9 and Resident #25), who had been incontinent of bowel, in a review of 17 sampled residents. The facility failed to post signs to alert staff and visitors to use precautions and appropriate personal protective equipment (PPE) for four residents (Resident #34, #35, #39 and #302) who were on isolation precautions and failed to close the door of one resident's room (Resident #39) who was on isolation precautions. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure ceiling vents were maintained free of a buildup of dust and debris. The census was 52. Observations on 10/17/23 between 9:20 A.M. and 6:30 P.M., showed the following: -In the biohazard room on the 100 hall, the ceiling vent had a moderate buildup of fuzzy debris; -In the full cylinder oxygen storage room, the ceiling vent had a moderate buildup of fuzzy debris; -In the sitting room (geri center) near the nurse's station, the ceiling vent had a heavy buildup of fuzzy debris; -At the nurses' station, the ceiling vent had a moderate accumulation of dust and debris; -In the unlabeled room, located next to the nurses' station and clean utility room, the ceiling vent had a heavy accumulation of dust; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust; [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Aide Registry prior to hire for five of ten employees reviewed, to ensure they did not have a Federal Indicator (the individual with a Federal Indicator cannot work in a certified long-term care facility). The facility failed to develop a policy to direct staff to check the Nurse Aide Registry prior to hiring new employees. The facility census was 52. Review of the undated facility policy, Employment Procedures, showed prior to employment, the facility is required by state regulation to check the state employment disqualification list, run a criminal record check and file application to the family safety care registry. The facility policy did not address checking the Nurse Aide Registry prior to hiring new staff members. 1. Review of Dietary Aide C's employee file showed the following: -Date of hire 07/21/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination of respiratory equipment according to facility policy, when staff failed to protect continuous positive airway pressure (CPAP)/Bilevel positive airway pressure (BiPap) (devices that helps with breathing) equipment and nebulizer treatment equipment when not in use, and failed to change oxygen tubing and ensure proper infection control was utilized according to facility policy for five residents (Resident #47, #152, #33, #4 and #7) in a review of 17 sampled residents. The facility census was 52. Review of the facility's undated Oxygen Tubing Policy, showed the following: -Maintenance: 10:00 P.M. to 6:00 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice and ensure proper administration of physician ordered insulin (medication used to treat diabetes) via an insulin pen for one resident (Resident #6), of 17 sampled residents and two additional residents (Resident #10 and Resident #22) when staff did not prime insulin pens prior to administration or hold the insulin pen in place for the appropriate amount of time during administration per policy and per the manufacturer's instructions. Failure to follow these procedure for administration results in residents not receiving the ordered dose of insulin. The facility census was 52. Review of the facility's policy for insulin injections, last revised in October 1990, did not address the procedure for insulin administration via insulin pens. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 52. (The facility was unable to provide a kitchen/dietary policy, food safety requirement policy, or food preparation guidelines policy). 1. During interview on 10/16/23 at 10:37 A.M., Resident #33 said he/she eats meals in his/her room. The morning and noon meals are not usually warm. During interview on 10/16/23 at 10:43 A.M., Resident #41 said he/she eats meals in his/her room. The supper meal is usually not warm when he/she gets her tray. 2. Observation on 10/17/23 at 12:08 P.M., showed the following: -The lunch meal consisted of ham steak, cheesy hash brown casserole, black-eyed peas, apple salad [NAME], corn bread and beverage; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Resident #3, #17 and #37), in a review of 17 sampled residents, and for one additional resident (Resident #4). The facility census was 52. Review of the undated facility policy, Resident Positioning Devices, showed no direction to staff regarding inspection of positioning devices for possible entrapment. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and 1/1/09, 803 incidents of patients getting caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct ongoing assessments of bed rails per facility policy to evaluate the continued need for the bed rail for two residents (Residents #3 and #4), in a review of 17 sampled residents. The facility census was 52. Review of the facility's undated policy, Resident Positioning Devices, showed the following: -Policy for resident positioning devices that are attached to residents' beds; -If a resident makes a request for a positioning device, our skilled nursing and/or therapy staff shall determine initial necessity; -The resident's primary care physician (PCP) shall be informed of the resident's request and the necessity for the facility to have an order for the device to be placed; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents (Residents #3, #19, and #25), in a review of 17 sampled residents. The facility census was 52. Review of the facility policy, Bed Hold Policy, revised 11/16/20, showed no instruction for staff as to their responsibility to provide written notice of bed hold to the resident and/or the resident representative. 1. Review of Resident #3's face sheet showed the resident was his/her own responsible party. Review of the resident's nurse notes, dated 02/13/23, showed the following: -The resident was very shaky, his/her skin was cold to touch; -The resident was unable to follow any nursing commands; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were labeled, dated or discarded when appropriate, failed to maintain the range hood from an accumulation of grease and debris and failed to maintain the freezer at 0 degrees Fahrenheit (F). The facility census was 54. 1. Observation on 2/4/20 at 11:26 A.M. of the walk-in cooler in the facility kitchen showed the following items: -A clear container with a green lid was labeled with masking tape lima beans 1/20/20; -A clear container with a red lid was labeled with a sticker chicken dumplings 1/21/20; -A clear container held pasta salad and was not labeled and was dated 1/24/20; -A clear container held sliced beets was not labeled or dated; -A clear container with a green lid was labeled with masking tape noodles 1/23/20; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain Nurse Aide (NA) registry/background screenings for four new employees, in a review of six newly hired employees prior to employment to determine if any had a Federal indicator with the nurse aide registry that would prohibit employment at the facility. The facility census was 54. 1. During interview on 2/7/20 at 11:55 A.M. the administrator said the facility did not have a policy regarding NA registry or background screenings. He did not know they needed to check the NA registry for non-nursing new hires since they checked the EDL (Employee Disqualification List) and FCR (Family Care Registry). The facility should follow the state regulation requirements. Review of the facility policy Employment Procedures showed the following employment procedures apply to all facility employees: 1. [...]