Concordia at Spiritrust Luther Ridge

In the surveyor’s words

From the most serious findings on record at Concordia at Spiritrust Luther Ridge, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 11, 2025

  Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm as evidenced by a fall with facial injury, which required sutures for one of three residents reviewed for falls (Resident 1). Findings include: Review of facility policy, titled Risk Management Incident/Accident Reporting Standard, with a last review date of May 21, 2025, revealed the facility identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. […]

• No harm, potential for more than minimal, patternF690Jun 11, 2026

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of one resident reviewed for catheters (Resident 8).Findings include: Facility policy, titled Catheter Care, Urinary, last reviewed January 2026, read, in part, The purpose of this procedure is to prevent infection of the resident's urinary tract. Catheter care is to be done every shift and as necessary. Review of Resident 8's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and obstructive and reflux uropathy (blockage of the urinary tract that causes urine to back up into one or both kidneys). […]

• No harm, potential for more than minimal, patternF698Jun 11, 2026

  Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one residents reviewed receiving dialysis (Resident 41).Findings include: A review of the facility policy, titled Hemodialysis Resident Care Standard, last reviewed January 2026, revealed that staff were to complete the pre-dialysis portion of the Hemodialysis Communication Record that provided information regarding the resident's ongoing status to send with the resident to dialysis. The policy stated, Assure the interchange of information with the dialysis clinic useful/necessary for the care of the resident. Use Hemodialysis Communication Form (#806NSG). […]

• No harm, potential for more than minimal, patternF756Jun 11, 2026

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for three of five residents reviewed (Residents 4, 7, and 8).Findings Include: Facility policy, titled Drug Regimen Review, last reviewed January 2026, read, in part, PROCEDURE: 1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physician and the care planning team. 2. Comments and recommendations concerning medication therapy are communicated in a timely fashion. […]

• No harm, potential for more than minimal, patternF684May 29, 2025

  Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the practitioner was notified of missed medication administration when medications were unavailable for four of 13 residents reviewed (Residents 12, 14, 15, and 19) and failed to provide treatment in accordance with professional standards of practice and physician orders for one of 13 residents reviewed (Resident 25). Findings include: Review of facility policy, Medication Administration, last revised June 2023, revealed, If a medication is not available, staff will notify the pharmacy provider immediately. […]