Luther Manor Retirement & Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 2, 2025

  Based on observation, interview and record review, the facility failed to provide oversight and prevent injury for two residents (Resident #1 and Resident #44) in a sample of 23 residents. Resident #1 was dependent on staff for transfers. When his/her electronic bed did not function properly, staff manually transferred the resident and caused a laceration to the resident's leg, which required emergency medical care, including sutures, antibiotic use to prevent infection, pain management medication, wound care and wound clinic appointments. Resident #44 had a history of falls and wandering and staff failed to provide oversight, resulting in an elopement that resulted in a fall with injury. The facility census was 55. […]

• Actual harm, isolatedF689Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to document and implement fall interventions to prevent falls for one resident (Resident #1), in a review of five sampled residents. On 07/06/25, staff failed to implement all interventions to prevent falls, including wedge cushions, while the resident was in bed. The resident rolled out of bed which resulted in a fracture of the tibia (a break of the larger of the two bones in the lower leg). The facility census was 55.Review of the facility's Fall Policy, dated 11/14/18, showed the following:-Purpose was to prevent a fall from occurring by identifying conditions and risk factors that typically lead to a fall. […]

• Actual harm, isolatedF686Aug 19, 2022

  Based on observation, interview and record review the facility failed to ensure one resident (Resident #1) of six sampled residents, received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) who the facility identified at risk for pressure ulcers. The resident initially presented with a superficial nickel size Stage II pressure ulcer to the coccyx. The pressure ulcer increased to quarter size and presented with slough (Stage III), with an additional ulcer, previously not identified, in the same area. The facility census was 52. […]

• No harm, potential for more than minimal, widespreadF812Oct 2, 2025

  Based on observation, interview, and record review, staff failed to store, prepare, and serve food in a safe and sanitary manner. Staff failed to ensure the temperature of a refrigerator used to store resident food was maintained at or below 45 degrees Fahrenheit (F) and the freezer was maintained at or below 0 degrees F. Staff failed to ensure food was discarded when it showed signs of deterioration. Staff did not practice proper handwashing, glove hygiene or hair restraint usage when preparing and serving food in the kitchen. Staff failed to ensure the facility's ice machine was clean and sanitary. The facility census was 55. The facility did not provide policies for food storage, dietary handwashing/gloving, hair restraints, ice machine cleaning, or storing resident food items. 1. […]

• No harm, potential for more than minimal, widespreadF880Oct 2, 2025

  Based on observation, interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) buy using gowns and gloves during high-contact resident care activities) and properly handle dirty linens for two residents (Resident #1 and #6) in a review of 23 sampled residents. Additionally, the facility failed to complete a required Legionella (a type of bacteria found in [NAME] that cased Legionnaires' disease, a severe form of pneumonia, when inhaled in water droplets or mist) program. The facility census was 55. […]