Luther Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Sep 10, 2024

  Surveyor: [NAME], [NAME] Based on observation, record review and interviews, the facility did not ensure that 1 (R62) of 5 residents reviewed received care, consistent with professional standards of practice to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing. * R62 developed a pressure injury on the right buttock on 6/30/24 that was not comprehensively assessed and did not have physician notification for a treatment until 7/10/24. R62's pressure injury declined during this time, and on 7/10/24, the wound physician assessed the pressure injury as unstageable. The wound physician ordered a debriding treatment. […]

• Immediate jeopardy, isolatedF692Sep 10, 2024

  Based on observation, record review, and interview, the facility did not ensure that 1 of 3 residents (R62) reviewed, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. * R62 was admitted with severe protein malnutrition. R62's nutritional assessments did not include actual weights that were obtained by facility staff and/or individualized interventions to provide adequate nutrition. […]

• Immediate jeopardy, isolatedF686Jun 11, 2024

  Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R7, R2, and R5) of 3 residents reviewed for pressure injuries. * On 5/14/24, R7 was identified as having a DTI (deep tissue injury) pressure injury to the right gluteal fold measuring 6 cm (centimeters) by 5 cm. A treatment of soap and water followed by Allevyn dressing every 72 hours continued through 6/2/24. On 5/15/24, APNP (Advance Practice Nurse Prescriber)-R assessed R7 to have an open area to the left ischial with necrotic tissue, odor, and drainage. […]

• Immediate jeopardy, isolatedF686May 27, 2021

  Based on record review and interview, the facility did not ensure that a resident who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care and treatment to promote healing for 1 (R2) of 2 residents reviewed for PI's. * R2 was admitted to the facility on [DATE]. A Licensed Practical Nurse (LPN) completed an admission evaluation, which included an initial skin check. A blanchable redness area was noted to the coccyx on admission. There was no RN review/assessment of the initial skin check on admission conducted by the LPN. On 4/19/21, R2 developed a facility acquired unstageable pressure injury to the coccyx. The LPN who discovered R2's pressure injury on 4/19/21 did not obtain measurements or a description of the wound. […]

• Actual harm, isolatedF686Jan 14, 2026

  Based on observation, interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 (R1 and R2) of 3 residents reviewed with pressure injuries. *R2 is at risk for developing pressure injuries. Facility staff did not document multiple weekly skin checks in the weeks prior to 8/31/25 when R2 developed a facility-acquired stage 3 pressure injury of R2's Sacrum. On 10/22/25, R2 developed two additional facility-acquired stage 2 pressure injuries to R2's right and left hip. On 11/23/25, R2's two hip pressure injuries were resolved but a week later, R2's left hip pressure injury re-opened. […]