Luther Acres Manor

In the surveyor’s words

From the most serious findings on record at Luther Acres Manor, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 29, 2026

  Based on review of facility policies, clinical record, facility documentation and interviews with staff, it was determined the facility failed to ensure a resident remained free from neglect, which resulted in actual harm to Resident R5 who sustained a left leg periprosthetic femur fracture for one of five residents reviewed (Resident R5). Findings include:Review of facility policy Resident Abuse Prevention and Reporting dated July 22, 2009, with a last revision date of November 28, 2016, and November 29, 2016, defines Neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of Resident R5's MDS (Minimum Data Set - mandatory periodic… […]

• No harm, potential for more than minimal, patternF880Feb 27, 2026

  Based on review of clinical records, observation and staff interview, the facility failed to maintain enhanced barrier precautions for three out of 18 residents reviewed (Residents 10, 11, and 21).Based on review of clinical records, observation and staff interview, the facility failed to maintain enhanced barrier precautions for three out of 18 residents reviewed (Residents 10, 11, and 21).Findings include:A review of facility policy entitled Enhanced Barrier Precautions, revised May 29. […]

• No harm, potential for more than minimal, patternF677Aug 7, 2025

  Based on review of observations and resident and staff interviews it was determined that the facility failed to provide activity of daily living (ADL) assistance for ten of eighteen residents (Residents R1, R3, R4, R5, R6, R7, R8, R9, R10, and R11).Findings include: During an observation on 8/7/25, at 10:38 a.m. when asked if she needed to wait an extended amount of time when she requests assistance with care, Resident R3 stated, Frequently on third shift. During an observation on 8/7/25, at 10:42 a.m. when asked if she needed to wait an extended amount to time when she requests assistance with care, Resident R4 stated, Depends on the aide. If we have agency people, then we wait. During an observation on 8/7/25, at 10:57 a.m. […]

• No harm, potential for more than minimal, patternF684Aug 7, 2025

  Based on review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the wounds for two of six residents (Resident R1 and R2). Findings Include: Review of the facility policy General Wound Management dated 7/22/25, indicated, Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF558Apr 14, 2026

  Based on clincal record review, faciltiy policy review, observations and staff and resident interviews, it was determined that the facility failed to ensure that call bells were answered in a timely manner for one resident observed (Resident 1).Findings include: During interview conducted with Resident 1 on April 14, 2026, at 11:12 a.m., the resident stated he/she had concerns with the length of time it takes for staff to respond to his/her call bell. Resident 1 stated that he/she required assistance with incontinence care and had initiated his/her call bell at approximately 11:00 a.m. A staff member, who Resident 1 later identified as dietary staff, knocked on the resident's door at 11:17 a.m. to inquire if Resident 1 needed assistance because his/her call bell was on. […]