Luther Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Jul 5, 2022

  Based on resident and staff interview and medical record review, the facility did not ensure Resident (R) wishes regarding code status were clearly and accurately identified for 2 of 22 residents (R38 and R39) investigated for Advance Directives. R38 verbalized the desire to be a full code. R38's medical record was inconsistent, identifying R38 as both a full code and a Do Not Resuscitate (DNR). Additionally, when R38 expressed a desire to be full code, the facility did not change the record until the next day. R39's medical record did not reflect R39's wishes to be DNR. Facility failure to clearly identify resident wishes for resuscitation created a finding of immediate jeopardy that began on [DATE]. […]

• Actual harm, isolatedF695Mar 29, 2021

  Based on record review and staff interview, the facility did not ensure that respiratory assessments were completed as ordered for 1 Resident (R) (R1) of 3 sampled residents. R1 had a nurse practitioner's order to conduct respiratory assessments two times per shift ordered on 3/16/21. Respiratory assessments were only completed two times per day following the 3/16/21 order. R1 developed symptoms of respiratory distress on 3/19/21 that required emergency transport to hospital with a subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: On 3/29/21, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was discharged to the hospital on 3/19/21 and readmitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Sep 14, 2023

  Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent or contain the transmission of communicable diseases and infection, including COVID-19. This had the potential to affect all 63 residents residing in the facility. The facility did not ensure staff performed proper hand hygiene during the provision of cares for 4 Residents (R) (R7, R8, R11, and R13) of 4 residents. The facility did not ensure staff wore eye protection in rooms of residents who were on isolation precautions related to COVID-19. The facility did not ensure staff wore an N95 respirator in a resident's room who was on isolation precautions related to COVID-19. […]

• No harm, potential for more than minimal, widespreadF812Jul 5, 2022

  Based on observation, staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 59 residents. Kitchen observations included: Food packages meant for resident consumption were found to be opened without open date or use-by date labels implemented. Food items meant for resident consumption were noted in the kitchen to be past use-by date(s). Food was removed from it's original containers without open/use-by dates or manufacturer expiration labels implemented. A fan was noted to be directed at the clean dish rack which contained dishes utilized to serve resident's food with a fire alarm device containing dust within the path of the fan's air flow. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2021

  Based on observation, staff interview and record review the facility did not store and prepare food under sanitary conditions according to professional standards of practice. This had to potential to impact all 74 residents residing at the facility. Grill was observed soiled with food residue. Work station above flour bins was observed with spilled pudding. Ovens under grill observed with burned food on bottom. Staff were observed not using appropriate hand hygiene during tray service. Cooler was observed to contain undated pan of sliced ham and undated container of meatballs. Findings include: Facility provided policy titled Hand Washing with a date of 2019 at bottom of document stated, Employees will wash hands as frequently as needed throughout the day using proper washing procedures . […]