Luther Manor at Hillcrest

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 12, 2026

  Based on observation, record review, staff interview and facility policy review the facility failed to follow fall interventions to prevent falls for 3 out of 4 residents reviewed with falls resulting in injuries. (Resident #11, #13 and #80). Staff failed to properly transfer Resident #11, resulting in a fractured ankle. The facility failed to follow fall interventions to prevent a fall for Resident #80, resulting in a hematoma and abrasion to forehead and a skin tear to left elbow. The facility failed to have interventions in place to prevent an abrasion to Resident #80's knee while in bed. The facility reported a census of 94 residents. Findings include. 1. […]

• Actual harm, isolatedF760Oct 23, 2025

  Based on clinical record review, staff interviews and facility policy review the facility failed to remove a transdermal patch prior to administering a new patch on 1 of 1 resident (Resident #2) which caused increased confusion and required an admission to the hospital for treatment of acute encephalopathy. The facility reported a census of 90 residents.Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #2, dated 8/8/25, revealed a list of diagnoses which included coronary artery disease, hypertension, Parkinson's disease, and bipolar disease. The MDS indicated the resident experienced short term memory problems and difficulty with decision making. The MDS assessed the resident required extensive assist with toileting, bathing and dressing. […]

• Actual harm, isolatedF697Sep 18, 2025

  Based on observation, clinical record review, staff and resident interview, along with policy and procedures, the facility failed to treat and manage pain, for 1 out of 3 resident reviewed (Resident #1) Resident #1 ran out of pain medication on 8/13/25-8/18/25, for which resulted in the resident being sent out to the local Emergency Department on 8/16/25 and 8/17/25 for pain medications. The facility reported a census of 99 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with a Brief Interview For Mental Status (BIMS) score of 15 for which indicated no cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observation, record review, interviews, and policy review the facility failed to prevent physical contamination of food in the kitchen during 4 observations. Hair nets were improperly worn, the cleaning schedule was not followed, and staff did not adequately sweep and mop floors to remove dead cockroaches. The facility reported a census of 94 residents. Findings include:During a kitchen observation on 2/04/26 starting at 10:20 AM noted the following:Staff I, Dietary Director, wore a brown hairnet that left about 2 inches of hair exposed over each ear and about 3 inches exposed in the backStaff P, Dietary Aide (DA), wore a white hairnet with about 2-3 inches of hair exposed in the back.Staff N, DA, wore a hairnet with about 1-2 inches of hair exposed in the back and about an inch… […]

• No harm, potential for more than minimal, widespreadF865Feb 12, 2026

  Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, review of the facility Quality Assurance and Performance Improvement (QAPI) documentation, QAPI policy review, and staff interview the facility failed to carry out QAPI activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting the facility. The facility reported a census of 94 residents.Findings include:The CMS 2567 Statement of Deficiencies dated 10/17/24 included the following concern: F812 Food Procurement, Store/Prepare/Serve-Sanitary.The CMS 2567 Statement of Deficiencies dated 12/30/24 included the following concerns: F812 Food Procurement,… […]