Luther Oaks

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 29, 2024

  Based on observation, interview, and record review, the facility failed to provide appropriate supervision for a dependent resident to prevent a fall, thoroughly investigate a fall, implement post fall interventions, and report a fall timely to the physician and resident representative for three of four residents (R1, R2, R3) reviewed for falls on the sample list of 18. This failure resulted in R1 falling in the bathroom after being left unattended and sustaining a head laceration requiring two staples. Findings include: 1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. This same MDS documents R1 is independent with cares and uses both a walker and wheelchair. […]

• Actual harm, isolatedF686Apr 24, 2023

  Based on observation, interview and record review, the facility failed to ensure a resident did not develop a pressure ulcer, failed to complete an initial or weekly wound assessments and failed to refer resident to the dietician for an evaluation of nutritional interventions to promote healing for one of three residents (R3) reviewed for pressure ulcers on the sample list of six. This failure resulted in R3 acquiring an unstageable pressure ulcer to the right heel on 1/11/23 and not receiving nutritional interventions to promote healing until 3/21/23. […]

• Actual harm, isolatedF689Apr 24, 2023

  Based on interview and record review, the facility failed to complete thorough post fall investigations for two residents (R1, R4). The facility also failed ensure a resident was supervised and using the appropriate transfer devices to prevent a fall for one of three residents (R1) reviewed for falls on the sample of six. This failure resulted in R1 falling while standing unassisted in the bathroom, sustaining a head laceration requiring four staples. Findings include: The facility's Fall Reduction Policy dated last revised on 1/5/2021 with next review dated 1/5/2022 documents that this policy is intended to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to… […]

• No harm, potential for more than minimal, widespreadF801Aug 1, 2024

  Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 16 residents residing in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 7/30/24 documents 16 residents reside in the facility. Throughout the survey from 7/30/24-8/1/24, the facility failed to keep the kitchen clean and free of debris in preparation and storage areas, failed to sanitize food preparation areas according to facility's sanitation policy, and failed to cover and contain ice cream canisters in the freezer. Kitchen staff also failed to contain hair while in the kitchen and food preparation areas. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview and record review the facility failed to store dishes in a sanitary manner, clean food preparation areas with appropriate chemicals, ensure staff's hair was secure to prevent food contamination, and ensure ice cream lids were in place to prevent cross contamination. These failures have the potential to affect all 16 residents who reside in the facility. Findings include: The Long Term Care Facility application for Medicare and Medicaid dated 7/30/24 documents 16 long term care residents reside in the facility. The facility policy Manual Cleaning and Sanitizing date revised 6/1/2021 documents Equipment, utensils, and tableware will be washed and sanitized in a method which complies with the Federal Food Code and any state or local ordinances. […]