Luther Memorial Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Feb 5, 2024

  Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 closed record (Resident #1) with diabetes. Failure to ensure residents receive treatment and care according to professional standards of practice related to blood glucose monitoring increases the risk of serious harm, impairment, or death. During the complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on [DATE] at 5:22 p.m. The IJ resulted from staff failure to recheck a resident's glucose [sugar] or take additional interventions after a test result of 61 mg/dL (milligrams per deciliter) on [DATE]. […]

• No harm, potential for more than minimal, patternF812Dec 31, 2025

  Based on observation, review of professional reference, and staff interview, the facility failed to ensure food is served in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure proper glove usage when serving food may result in foodborne illness to residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, pages 61-62, stated, . 3-304.15 Gloves, Use Limitation. (A)If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observation of the tray line in the main kitchen on 12/30/25 at 11:15 a.m. […]

• No harm, potential for more than minimal, patternF689May 19, 2021

  Based on observation, record review, and staff interview, the facility failed to provide assistance and supervision necessary to prevent accidents for 3 of 9 sampled residents (Resident #14, #31, and #70) identified with falls. Failure to provide supervision and adequate assistance with transfers/ambulation may result in falls and injuries. Findings include: - Review of Resident #14's medical record occurred on all days of survey. Diagnoses included dementia, a history of a right femur fracture, and a history of falls. The current care plan stated, . Problem . IMPAIRED MOBILITY/AMBULATION R/T [related to]: Fractured Right hip/femur . Alzheimer's . Approach . Transfers: Extensive assist of 2 . gait belt- yes . Walking in Corridor: Ext [extensive] assist of 2. Gait belt: Yes . […]

• No harm, potential for more than minimal, isolatedF641Dec 31, 2025

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents (Resident #10). Failure to accurately complete Section M (Skin Conditions) of the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan, and the care provided to the residents.Findings include:The Long-Term Care Facility RAI 3.0 User's Manual, (Version 1.20.1), revised October 2025, page M-24, stated, M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar . […]

• No harm, potential for more than minimal, isolatedF880Dec 31, 2025

  Based on observation, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 1 of 6 sampled residents (Resident #10) observed during cares. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors.Findings include:Review of Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 685, stated, . Gloves . […]