Luther Woods Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Luther Woods Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF814Nov 21, 2025

  Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.Findings include: Observations in the receiving area conducted on November 18, 2025, at approximately 10:30 a.m. revealed piles of leaves covering multiple wooden pallets. Empty cans, dirty napkins, and cardboard boxes were observed mixed within the leaves. Further observations in the trash area revealed that the compactor and recycling containers were open, and black trash bags were exposed without lids. Furniture, including couches and chairs, was piled in the same area, with one couch positioned between the compactor and recycling box. […]

• No harm, potential for more than minimal, patternF585Nov 21, 2025

  Based on review of facility policy, staff and resident interviews, and observation, it was determined that the facility did ensure a formal grievances process was in place for two of three units observed. (A Wing, B Wing). Findings Include: Review of the facility policy titled Grievances dated January 23, 2020 states, Policy- the patient has the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion. […]

• No harm, potential for more than minimal, patternF812Nov 21, 2025

  Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: Review of facility policy titled, Cleaning dishes/Dish Machine undated, indicated that staff must check the dish machine gauges throughout the cycle to assure proper temperatures and sanitation. Observations conducted on November 18, 2025, at 10:12 a.m. revealed while the low-temperature dish machine was running, a review of the sanitizer ppm test strip with the Food Service Director (FSD), Employee E 14 revealed no color change, indicating no chlorine present. The acceptable range is 50-100 ppm. […]

• No harm, potential for more than minimal, patternF550May 18, 2023

  Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for eight of 16 dining tables observed. Findings include: Observations of the main dining room on May 15, 2023, at 12:15 p.m. revealed the following: Three tables with two residents seated at each table, only one of two residents was served a meal. Further observations revealed three tables with three residents seated at each table, two residents were served a meal and one was not. Follow-up observations of the main dining room on May 16, 2023, at 12:08 p.m. revealed the following: Four tables with two residents seated at each table, one resident was served a meal and one resident was not. […]

• No harm, potential for more than minimal, patternF584May 18, 2023

  Based on observations, staff and resident interviews, and facility documentation, it was determined that the facility did not provide a safe, clean, comfortable and homelike environment for two of 25 residents. (Residents R36 and R74) Findings include: A review of clinical record of Resident 74 revealed she was admitted to the facility on [DATE] with the diagnoses of unsteadiness on feet, muscle weakness and difficult in walking. Review of Resident R74's Admission Minimum Data Set (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) assessment dated , March 28, 2023, indicated that the resident's cognition was intact. […]