Luther Woods Nursing and Rehabilitation Center

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement contact precautions for three of three resident rooms reviewed (room [ROOM NUMBER], 225, and 216).

Inspectors wroteBased on review of clinical records, facility policy and interview with staff, it was determined that the facility failed to conduct a complete and through investigation for an allegation of missing potential narcotic medication for 1 out of 2 residents reviewed (Resident R2).

Inspectors wroteBased on clinical record review, facility policy and documentation, and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of one residents reviewed for elopement risk (Resident R1).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and reconciled for two out of two residents reviewed. (R2, R3)

Inspectors wroteBased on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for one of one resident reviewed for elopment risk (Resident R1).

Inspectors wroteBased on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on review of facility policy, staff and resident interviews, and observation, it was determined that the facility did ensure a formal grievances process was in place for two of three units observed. (A Wing, B Wing). Findings Include: Review of the facility policy titled Grievances dated January 23, 2020 states, Policy- the patient has the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion. A tour was taken with the facility Social Worker, Employee E9 on November 19, 2025 to identify where postings and grievance paperwork was located for residents. [...]

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of facility policy, observations, review of clinical records, and interviews with staff and residents it was determined that the facility did not ensure to develop and implement comprehensive person-centered care plans for each resident and develop goals and interventions related to residents refusals, behaviors and residents diagnosed with Dementia, and PTSD for five of 26 resident records reviewed (Residents R3, R10, R11, R19, R136).

Inspectors wroteFalling under Comprehensive Resident Centered Care Plan- The facility did ensure services provided met professional standards related to medication administration for one resident. Number of residents sampled:Number of residents cited:

Inspectors wroteBased upon interviews with the resident, resident's family and staff interviews, review of clinical records, facility documentation and policies it was determined that the facility failed to ensure a resident admitted with a pressure ulcer received the necessary treatment and services, in a timely manner, consistent with professional standards of practice, to promote healing and prevent infection for one of 26 resident records reviewed (Resident R148).

Inspectors wroteBased on clinical record review, review of facility policy and interviews with residents and staff, it was determined that the facility did not ensure that physician's orders were obtained regarding oxygen therapy for one resident out of 26 residents reviewed. (Resident R45)

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that controlled drugs subject to abuse are stored and labeled in accordance with professional standards for one of two medication rooms observed (B wing medication room).

Inspectors wroteBased on observation, staff and resident interview, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on two of three nursing units. (B Unit and C Unit ).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level in reference to communication for one of 26 residents reviewed (Resident 75).

Inspectors wroteBased on review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss (Resident R65 and R30).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for one of 26 residents reviewed (Resident R45). Findings Include: Review of facility policy Medication Management/Medication Unavailability dated 04/21/2022 revealed the pharmacy provides and maintains written contractual services and procedures that ensure safe and effective drug therapy, distribution, control and use within the facility. If medications are determined to be unavailable for administration, the licensed nurse will notify the provider of the unavailability and request an alternate treatment if possible. The licensed nurse will document notification to the provider of the unavailability in the medical record. [...]

Inspectors wroteBased on review of facility documents and resident clinical record reviews and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for four of 4 residents reviewed (Resident R35, R48, R93, R113,).