Luther Haven

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 13, 2025

  Based on observation, interview, and document review the facility failed to complete a timely comprehensive elopement risk assessment that addressed window type as a possible exit for mobile residents who were at risk for elopement for 1 of 3 residents (R1) who had a history of exit seeking. This resulted in immediate jeopardy (IJ) when R1 eloped from a window in her room and was found 1/2 mile from the facility approximately an hour later by the police and family member. The immediate jeopardy began on 12/28/24, when R1 eloped from the facility by exiting through the window in her room and was found an hour later 1/2 mile from the facility. The immediate jeopardy was identified on 1/9/25, and the assistant administrator was notified on 1/9/25, at 4:40 p.m. […]

• Immediate jeopardy, isolatedF689Sep 12, 2024

  Based on observation, interview, and document review, the facility failed to appropriately assess and/or follow the care plan and ensure safe transfers were performed for 3 of 3 residents (R11, R16, and R37) while using sit-to-stand mechanical lifts (EZ stand) (requires a resident to be partial weight-bearing) to prevent or mitigate falls or risk thereof. This resulted in an immediate jeopardy (IJ) for both R11 and R16 who fell from and EZ-stand and required hospital evaluation and treatment). Both events had the potential for serious harm, injury, impairment, or death. The IJ began on 8/29/24, when nurse aide (NA)-A failed to follow R11's care plan and ensure 2 staff transferred R11 while using an EZ-Stand. […]

• Actual harm, isolatedF689Jun 5, 2025

  Based on interview and document review, the facility did not assess or analyze trends of falls to determine causal factors or root cause and implement interventions to prevent or reduce the risk of falls with major injury for 1 of 3 residents (R1) reviewed who had falls. This resulted in actual harm when R1 suffered spinal compression fracture at T12 (thoracic spine last vertebrae), L1 and L2 (lumbar spine between the top two vertebrae) and a rib fracture as a result of two unsupervised falls. Findings include: R1's face sheet dated 6/5/25, identified diagnoses of Parkinson's disease (condition that affects movements), dementia (decline in mental ability), and depression (mood disorder characterized by persistent sadness). […]

• No harm, potential for more than minimal, widespreadF585Sep 12, 2024

  Based on interview and document review the facility failed to ensure 1 of 1 grievance policy and procedures were followed. The facility failed to post the grievance policy prominently and throughout the facility and provide forms to submit a grievance anonymously if desired. In addition, the facility also failed to document all grievances, the action taken to resolve grievances and the summary of the resolution to each grievance. This had the ability to affect all 54 residents. Findings include: Interview on 9/9/24 at 12:09 p.m., with R39 who reported that he must wait for someone to come help him. He likes to get up around 7:30 a.m., and no one came to help him until 9:00 a.m. and he was so mad he could have burnt the place up. Interview on 9/9/24 at 1:27 p.m. […]

• No harm, potential for more than minimal, widespreadF726Sep 12, 2024

  Based on interview and record review, facility failed to ensure 8 of 8 nursing assistants ((NA)-A, NA-B, NA-F, NA-G, NA-H, NA-I, NA-J, and NA-K) 4 of 4 registered nurses (RN)-D, RN-E, RN-F and the infection preventionist (IP)), and 1 of 1 licensed practical nurse (LPN)-F were deemed competent on the operatioon of mechanical lifts and following care plans and care sheets, upon hire, yearly thereafter, or as needed when identified concerns with competence were noted. This had the potential to affect all 54 residents who had/may use mechanical lifts, and had care plans and care sheets. Findings include: Review of the NA employee files identified: 1. NA-A had a hire date of 8/27/24. 2. NA-B had a hire date of 2/4/22. 3. NA-F had a hire date of 3/27/24. 4. NA-G had a hire date of 6/11/24. […]