Luther Crest Nursing Facility

In the surveyor’s words

From the most serious findings on record at Luther Crest Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF697Jun 3, 2022

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 15 sampled residents. (Residents 22, 48) Findings include: Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident experienced occasional mild pain. Narcotic pain medication ([MEDICATION(S)]) was ordered by the physican on March 23, 2022, for 50 milligrams (mg) every six hours as needed for pain. […]

• No harm, potential for more than minimal, patternF730Jun 3, 2022

  Based on facility policy review, staff education documentation review, and staff interview, it was determined that the facility failed to ensure staff completion of regular annual training, including no less than 12 hours of in-service education, for four of five sampled nurse aides. (NA 1, NA 2, NA 3, NA 4) Findings include: The facility policy entitled, Employee Training/Development, dated November 20, 2021, indicated that mandatory and voluntary continuing education opportunities were utilized on an ongoing basis to ensure that employees had sufficient training and information to competently perform job responsibilities and that mandatory trainings were required. […]

• No harm, potential for more than minimal, patternF758Jun 3, 2022

  Based clinical record review and staff interview, it was determined that the facility failed to ensure that non-pharmacological behavioral interventions were provided prior to or in conjunction with the administration of [CONDITION(S)] medication prescribed on an as needed basis for one of 15 sampled residents. (Resident 22) Findings include: Clinical record review revealed that Resident 22 was had diagnoses that included dementia with behavioral disturbance, visual hallucinations, depression, adjustment [CONDITION(S)], and anxiety disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident exhibited some depression and trouble falling asleep and no behavioral symptoms in the previous seven day assessment period. […]

• No harm, potential for more than minimal, patternF943Jun 3, 2022

  Based on facility policy review, staff education documentation review, and staff interview, it was determined that the facililty failed to ensure that annual training for dementia management and resident abuse prevention and reporting was completed by six of nine sampled staff. (NA 1, NA 2, NA 3, NA 4, LPN 1, LPN 2) Findings include: The facility policy entitled, Abuse/Neglect/Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Such training shall include resident rights and appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. […]

• No harm, potential for more than minimal, isolatedF641Jun 5, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's current status for one of 13 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus, muscle weakness, need for assistance with personal care, and major depressive disorder. A physician's orders dated April 21, 2024, July 22, 2024, and March 28, 2025, directed staff to apply and monitor an electronic monitoring device to the resident's arm. […]