Katherine Luther Residential HLTH Care & Rehab

In the surveyor’s words

From the most serious findings on record at Katherine Luther Residential HLTH Care & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 24, 2024

  Based on record review and interview during the abbreviated and extended survey (NY00323717), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 6 residents reviewed (Resident #2 and #7. Specifically, Resident #2 had a fall with a hematoma (pooling of blood under the skin) to the back of their head and neurological checks were not completed. When the resident had a change in condition (lethargy, sluggish eye movement, slow to speak, and vomiting), a medical provider was not notified in a timely manner (approximately 2 hours after symptoms began). Additionally, a delay in transport to the hospital occurred when the facility was not able to reach Emergency Medical Services. […]

• Actual harm, patternF692Jun 26, 2026

  Based on observations, record review, and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for three of eight residents (Residents #10, #108, and #113) reviewed. Specifically, Resident #10 had significant weight loss from 12/17/2025-06/11/2026 and there was no documented evidence interventions were implemented to address the weight loss, weekly weights were completed as recommended by the registered dietitian, or the care plan was reviewed and revised after the significant weight loss. Resident #108 had significant weight loss from 05/07/2026-06/24/2026 and there was no documented evidence interventions were implemented to address the weight loss. […]

• Actual harm, isolatedF600Jun 26, 2026

  Based on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for one of one resident (Resident #167) reviewed. Specifically, Resident #167 required assistance of two for transfers using a mechanical lift and on 05/19/2025, Certified Nurse Aide #21 used a stand pivot transfer without assistance resulting in a fractured right arm. This resulted in actual harm to Resident #167 that was not Immediate Jeopardy. Findings include: The facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed 01/15/2024, documented that each resident would be free from abuse or neglect and would not be tolerated. […]

• Actual harm, isolatedF677Jun 26, 2026

  Based on observations, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of seven residents (Resident #113) reviewed. Specifically, Resident #113 experienced significant weight loss and did not receive assistance with meals as planned. This resulted in actual harm to Resident #113 that was not Immediate Jeopardy.Findings include:The facility policy Supporting Activities of Daily Living, revised 10/15/2024, documented residents would receive the services necessary to maintain good nutrition including appropriate support and assistance with meals and snacks. […]

• Actual harm, isolatedF686Jun 26, 2026

  Based on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident #26) reviewed. Specifically, on 05/21/2026, Resident #26 developed a pressure ulcer on the hip, and a comprehensive wound assessment, physician notification, treatment plan, and nutritional assessment were not completed timely. Subsequently, the pressure ulcer progressed to a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). This resulted in actual harm to Resident #26 that was not Immediate Jeopardy. […]