Inspection Reports for
Luther Manor Retirement &Amp; Nursing Center
3170 HIGHWAY 61 NORTH, HANNIBAL, MO, 63401-6571
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
176% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
86% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 55
Deficiencies: 12
Date: Oct 2, 2025
Visit Reason
Routine inspection of Luther Manor Retirement & Nursing Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident fund management, code status documentation, background screening for employees, transfer/discharge notifications, accident prevention, incontinent care, food safety and temperature control, infection control practices, facility-wide assessment updates, quality assurance processes, and legionella water management.
Deficiencies (12)
F 0568: Facility failed to maintain individual resident ledgers for resident funds, send quarterly statements, and distribute accrued interest properly for two residents.
F 0578: Facility failed to document residents' code status for CPR clearly and accessibly, affecting five residents.
F 0607: Facility failed to complete required background screenings including criminal background checks and NA registry checks prior to employment for multiple staff.
F 0628: Facility failed to provide written transfer/discharge notices with required information to residents and representatives for three residents and failed to notify the Ombudsman.
F 0689: Facility failed to provide adequate supervision and prevent injury for two residents, resulting in a laceration and an elopement with injury.
F 0690: Facility failed to provide proper incontinent care and infection control for a resident with an indwelling catheter, risking urinary tract infection.
F 0804: Facility failed to serve meals at safe and appetizing temperatures; multiple residents reported cold food.
F 0812: Facility failed to maintain safe food storage temperatures, practice proper hand hygiene and glove use, wear hair restraints, and maintain a clean ice machine.
F 0838: Facility failed to update and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care.
F 0867: Facility failed to implement an effective quality assessment and assurance committee with documented corrective plans.
F 0880: Facility failed to utilize Enhanced Barrier Precautions properly for residents with multidrug-resistant organisms and failed to handle contaminated linens according to policy. Facility also lacked a comprehensive Legionella water management program.
F 0947: Facility failed to ensure nurse aides received the required 12 hours of annual in-service education including dementia care and abuse prevention.
Report Facts
Facility census: 55
Resident fund interest amounts: 3.86
Resident fund interest amounts: 2.41
Resident fund interest amounts: 1
Resident fund interest amounts: 1.04
Resident fund interest amounts: 1.3
Resident fund interest amounts: 1.67
Resident fund interest amounts: 1.42
Resident fund interest amounts: 1.47
Facility refrigerator temperature: 49
Facility freezer temperature: 23
Food temperature: 96.1
Food temperature: 100.7
Food temperature: 107.4
Food temperature: 114.1
Food temperature: 104.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| CNA O | Certified Nurse Assistant | Named in wound care and infection control deficiencies |
| CNA G | Certified Nurse Assistant | Named in Enhanced Barrier Precautions deficiency |
| CNA F | Certified Nurse Assistant | Named in Enhanced Barrier Precautions deficiency |
| Cook BB | Cook | Named in food handling and hygiene deficiencies |
| Dietary Manager | Dietary Manager | Named in food temperature and hygiene deficiencies |
| Housekeeper M | Housekeeper | Named in soiled linen handling deficiency |
| Administrator | Administrator | Named in background screening and facility assessment deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including infection control and education |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection control and wound care deficiencies |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 3
Date: Oct 2, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident safety, facility-wide assessment, and staff training.
Findings
The facility failed to provide adequate supervision and accident prevention, resulting in injuries to residents during transfers and elopement incidents. The facility also failed to update and document a facility-wide assessment and did not ensure nurse aides received required annual in-service education.
Deficiencies (3)
F 0689: The facility failed to prevent injury during resident transfers and failed to provide adequate supervision to prevent elopement and falls, resulting in actual harm to residents.
F 0838: The facility failed to update and document a facility-wide assessment to determine necessary resources for competent resident care during daily operations and emergencies.
F 0947: The facility failed to ensure nurse aides received the required 12 hours of annual in-service education, including dementia care and abuse prevention.
Report Facts
Facility census: 55
Resident sample size: 23
Laceration length: 15
Laceration depth: 10
Antibiotic treatment duration: 10
Wound length: 13.5
Fall injury abrasion size: 5
Fall injury abrasion size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Named in transfer injury incident and wound care |
| CNA C | Certified Nurse Assistant | Involved in resident transfer during injury incident |
| CNA S | Certified Nurse Assistant | Involved in resident transfer during injury incident |
| Director of Nursing | Director of Nursing (DON) | Provided interview on transfer procedures and staff education |
| LPN B | Licensed Practical Nurse | Involved in assessment and care after resident fall and elopement |
| ADON | Assistant Director of Nursing | Provided interview and nursing note related to resident fall |
| CNA T | Certified Nurse Assistant | Last staff to see resident before elopement incident |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to document and implement fall interventions to prevent falls for a resident, which resulted in injury.
Complaint Details
The investigation was complaint-related, focusing on a resident who fell on 07/06/25 due to failure to use fall prevention wedge cushions. The fall resulted in a fracture. Staff interviews revealed poor communication and lack of knowledge about interventions. The complaint was substantiated with actual harm.
Findings
The facility failed to implement all fall prevention interventions, including the use of wedge cushions for a high-risk resident, leading to a fall and fracture. Staff communication and documentation of interventions were inadequate, and new staff were unaware of required interventions.
Deficiencies (1)
F 0689: The facility failed to document and implement fall interventions, including wedge cushions, for a resident at high risk for falls, resulting in a fall and tibia fracture. Staff were unaware or did not use the wedge cushions, and care plan updates and interdisciplinary team meetings were lacking.
Report Facts
Facility census: 55
Fall event dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Completed fall event report on 07/06/25 and provided interview about fall interventions |
| CNA A | Certified Nurse Assistant | Assisted resident on 07/06/25 but did not use wedge cushions due to lack of knowledge |
| CNA B | Certified Nurse Assistant | Assisted resident on 07/06/25 but did not use wedge cushions due to lack of knowledge |
| LPN C | Licensed Practical Nurse | Provided interview about fall interventions and wedge cushion use |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations for fall prevention interventions |
| Care Plan Coordinator | Care Plan Coordinator | Interviewed about care plan documentation and interdisciplinary team meetings |
| Administrator | Administrator | Interviewed about expectations for staff to follow fall prevention interventions |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jun 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a resident's physician about hip pain following a fall.
Complaint Details
The investigation was complaint-related, focusing on the failure to notify the physician timely about the resident's hip pain after a fall. The complaint was substantiated based on interviews and documentation review.
Findings
The facility failed to notify the physician timely of a resident's hip pain after a fall on 05/21/25, resulting in a delayed diagnosis of a fractured hip. Multiple staff interviews and record reviews confirmed the lack of timely communication despite the resident's complaints and administration of pain medication.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician timely of hip pain following a fall on 05/21/25, resulting in delayed diagnosis of a left hip fracture.
Report Facts
Facility census: 54
Pain medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented the fall and initial resident complaints; did not notify physician of hip pain |
| LPN B | Licensed Practical Nurse | Administered Tylenol for hip pain; did not recall notifying physician |
| LPN E | Licensed Practical Nurse | Administered Tylenol at 11:45 P.M.; did not notify physician of resident's pain |
| RN C | Registered Nurse | Notified physician via fax on 05/23/25 about the fall and pain complaints |
| Certified Nurse Assistant D | Certified Nurse Assistant | Witnessed the fall and resident's initial complaint of pain |
| Resident's Nurse Practitioner | Nurse Practitioner | Expected timely notification of resident's hip pain and stated he would have ordered an x-ray earlier |
| Director of Nursing | Director of Nursing | Expected staff to notify physician of any complaints of pain |
| Administrator | Administrator | Expected staff to notify physician of any complaints of pain |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: May 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin involving a resident's fractured humeral shaft.
Complaint Details
The complaint investigation focused on whether the facility properly reported an injury of unknown origin for Resident #1 who had a new fracture of the left humeral shaft. The facility did not report the injury as required. Interviews with nursing staff, the Director of Nursing, Assistant Director of Nursing, and Administrator confirmed the fracture was not reported because it was not considered new or of unknown origin until the state agency investigation.
Findings
The facility failed to report a new fracture of unknown origin for one resident who had surgery for a left humerus fracture. Interviews revealed staff and administration did not consider the new fracture an injury of unknown origin and thus did not report it to the state agency as required.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or injury of unknown origin involving a resident's new fractured humeral shaft to the state survey agency. The resident had no falls or trauma while at the facility, but the new fracture requiring surgery was not reported.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented resident's follow-up appointment and reported fracture to DON and ADON |
| ADON | Assistant Director of Nurses | Interviewed regarding resident's readmission and fracture reporting |
| DON | Director of Nurses | Interviewed regarding fracture reporting and knowledge of resident's condition |
| Administrator | Administrator | Interviewed regarding knowledge of fracture and reporting to state agency |
Inspection Report
Routine
Census: 52
Deficiencies: 10
Date: Oct 18, 2023
Visit Reason
Routine inspection of Luther Manor Retirement & Nursing Center to assess compliance with health, safety, and regulatory standards.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, staff compliance with hiring and infection control policies, medication administration, food safety, and bed safety. Several residents were affected by issues such as improper infection control, failure to provide written bed hold notices, improper insulin administration, and failure to maintain safe bed rails.
Deficiencies (10)
F 0584: Facility failed to ensure ceiling vents were maintained free of dust and debris, with moderate to heavy buildup observed in multiple areas and resident rooms.
F 0607: Facility failed to check the Nurse Aide Registry prior to hire for five employees and lacked a policy requiring this check.
F 0625: Facility failed to provide written notice of bed hold policy to residents or representatives prior to hospital transfers for three residents.
F 0695: Facility failed to ensure proper infection control for respiratory equipment and oxygen tubing for five residents, including uncovered BiPap masks and outdated nebulizer tubing.
F 0700: Facility failed to conduct ongoing assessments of bed rails per policy for two residents and did not monitor positioning devices as bed rails.
F 0760: Facility failed to ensure proper administration of insulin via insulin pens for three residents, including failure to prime pens and hold injection site for required time.
F 0804: Facility failed to provide food items at safe and appetizing temperatures, with hot foods served below 120°F and cold foods above 41°F.
F 0812: Facility failed to ensure dietary equipment and ice machine were clean and properly maintained, including grease buildup and lack of air gap on ice machine drain.
F 0880: Facility failed to ensure proper infection control, including failure to wash hands after glove removal during incontinent care, failure to post isolation signs and close isolation room doors, and incomplete TB testing for new employees.
F 0909: Facility failed to complete regular inspection of bed frames, mattresses, and bed rails for entrapment hazards for four residents.
Report Facts
Resident census: 52
Temperature of ham steak: 114
Temperature of apple salad: 58
Temperature of roast beef and Swiss sandwich: 101.5
Temperature of carrot and raisin salad: 64.2
Temperature of milk: 63.1
Temperature of yogurt: 68.4
Blood sugar level: 266
Units of insulin administered: 9
Units of insulin administered: 10
Units of insulin administered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed administering insulin without priming pen or holding injection site |
| DON | Director of Nursing | Observed failing to wash hands between glove changes during incontinent care |
| CNA Q | Certified Nurse Assistant | Observed failing to wash hands between glove changes during incontinent care |
| CNA K | Certified Nurse Assistant | Observed failing to wash hands between glove changes during incontinent care |
| Dietary Aide C | Employee file missing documentation of second step TB test reading | |
| CNA G | Certified Nurse Assistant | Employee file missing documentation of TB test results and facility TB testing |
| CNA I | Certified Nurse Assistant | Employee file missing documentation of TB testing |
| Caregiver J | Employee file missing documentation of second step TB test | |
| Dietary Aide H | Employee file with incomplete TB test documentation | |
| CNA K | Certified Nurse Assistant | Employee file with incomplete TB test documentation |
| Infection Preventionist/ADON | Assistant Director of Nursing | Responsible for TB testing and infection control oversight |
Inspection Report
Life Safety
Census: 52
Capacity: 64
Deficiencies: 9
Date: Oct 18, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate the facility's compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found deficient in multiple areas including failure to annually review and update the emergency preparedness plan, unsealed vertical openings and ceiling penetrations compromising fire barriers, failure to maintain corridor doors to resist smoke passage, inadequate smoke barrier construction, failure to conduct fire drills at required intervals, improper smoking area maintenance, and failure to maintain fire-rated door assemblies and electrical safety standards.
Deficiencies (9)
E004 Emergency Plan. The facility failed to review and update the emergency preparedness plan annually as required by regulation.
K311 Vertical Openings - Enclosure. The facility failed to maintain fire resistance rating of at least one hour for vertical openings between floors, with multiple unsealed holes and missing ceiling tiles.
K363 Corridor - Doors. The facility failed to maintain corridor doors to resist smoke passage, with multiple doors having gaps up to 0.5 inches.
K372 Smoke Barrier Construction. The facility failed to maintain smoke barriers complete from outside wall to outside wall, with multiple unsealed gaps and penetrations.
K712 Fire Drills. The facility failed to conduct fire drills at unpredictable times and at least quarterly on each shift as required.
K741 Smoking Regulations. The facility failed to maintain smoking areas to ensure proper disposal of cigarette butts and ashes, creating fire hazards.
K761 Maintenance, Inspection & Testing - Doors. The facility failed to ensure annual inspection and maintenance of one-fire rated door assemblies.
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to ensure proper use and inspection of power strips and extension cords in patient care areas.
K923 Gas Equipment - Cylinder and Container Storage. The facility failed to ensure oxygen cylinders were stored properly within five feet of combustibles.
Report Facts
Facility census: 52
Facility capacity: 64
Fire drills conducted: 4
Fire drills required: 7
Residents potentially affected: 31
Residents potentially affected: 52
Residents potentially affected: 17
Oxygen cylinders stored: 50
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to readmit a resident who required emergent care and was sent to the hospital, due to the facility's inability to find an accepting physician to oversee the resident's care.
Complaint Details
The complaint investigation found that the facility denied readmission to a resident after hospital transfer due to no physician available to oversee care. The resident was discharged with a 30-day notice and later an immediate discharge notice. The resident's family appealed and found a physician, but the resident was still sent to the hospital due to condition changes. The Medical Director stated no restriction on readmission but expected the facility to defer to him for orders until a new physician was chosen.
Findings
The facility failed to readmit one resident after hospital transfer because no physician was available to oversee care. The resident was discharged with a 30-day notice, and subsequent attempts to re-admit were denied due to lack of physician coverage, despite family efforts to secure a new physician.
Deficiencies (1)
F 0622 - The facility failed to transfer or discharge a resident without an adequate reason and did not provide proper documentation and information when the resident was discharged. The resident was discharged due to lack of an accepting physician and was not readmitted after hospital transfer.
Report Facts
Facility census: 52
Discharge notice effective period: 30
Dates: Apr 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director | Medical Director | Discussed resident care goals and discharge process; stated no restriction on readmission |
| Administrator | Administrator | Issued discharge notices and attempted to serve emergency discharge notice at hospital |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with transfer and discharge requirements following a complaint or incident involving Resident #1's discharge and readmission process.
Findings
The facility failed to readmit Resident #1 after hospital discharge due to lack of a primary care physician and did not follow proper transfer and discharge documentation and procedures. The facility census was 52 at the time of inspection.
Deficiencies (2)
F622 Transfer and Discharge Requirements: The facility failed to readmit Resident #1 after hospital discharge due to lack of a primary care physician and did not ensure proper documentation and communication for transfer or discharge.
A8016 Reasons to Transfer/Discharge: A resident may be transferred or discharged only for medical reasons or for his or her welfare or that of other residents, or for nonpayment. This regulation was not met as evidenced by the failure to readmit Resident #1.
Report Facts
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Parker | Administrator | Signed the plan of correction and is referenced in the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CDC recommended practices for COVID-19 preparedness.
Complaint Details
This was a complaint investigation related to COVID-19 focused infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Aug 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer prevention and treatment at Luther Manor Retirement & Nursing Center.
Findings
The facility failed to ensure one resident received necessary treatment and services to prevent and heal pressure ulcers. Documentation of skin assessments and wound measurements was incomplete, and wound care protocols were not consistently followed.
Deficiencies (2)
F 686: The facility failed to provide care consistent with professional standards to prevent and treat pressure ulcers for one resident. Documentation of skin assessments and wound measurements was missing for multiple periods.
A4083: Facilities shall keep residents free from avoidable pressure sores by providing adequate treatment. This regulation was not met as evidenced by the pressure sore deficiencies cited under F686.
Report Facts
Facility census: 52
Deficiencies cited: 2
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to provide proper written notice before transferring or discharging a resident, specifically regarding a resident who was transferred to the hospital and denied re-admission.
Findings
The facility failed to provide a written notice of discharge with required information to the resident and/or representative. The facility's policy did not address refusal of readmission, 30-day discharge notice, or emergency discharge. The resident was discharged without proper notice and the facility was unable to meet the resident's advanced dementia care needs.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide a written discharge notice with required information to the resident and/or representative for one resident. The facility's policy did not address refusal of readmission or 30-day discharge notice requirements.
A8017 Discharge Appeal Rights: The facility did not provide full and adequate notice of the resident's right to a hearing before discharge, violating regulatory requirements.
Report Facts
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to communication with hospital staff and resident placement concerns |
| Social Services Director | Social Services Director | Interviewed regarding resident discharge and facility placement issues |
| Administrator | Administrator | Involved in notification and communication about resident discharge and facility policies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Feb 7, 2020
Visit Reason
The inspection was conducted to investigate complaints related to failure to obtain Nurse Aide registry/background screenings for new employees and to assess food safety practices including labeling, storage, and equipment maintenance.
Complaint Details
The visit was complaint-related due to failure to perform required Nurse Aide registry checks on new employees and concerns about food safety practices including labeling, storage, and equipment maintenance. The deficiencies were substantiated.
Findings
The facility failed to obtain Nurse Aide registry checks for four new employees prior to employment and did not have a policy addressing this. Additionally, the facility failed to ensure food items were properly labeled, dated, or discarded, failed to maintain the kitchen range hood free of grease and debris, and failed to maintain the freezer at the required 0 degrees Fahrenheit.
Deficiencies (2)
F 0607: The facility failed to obtain Nurse Aide registry/background screenings for four new employees prior to employment as required by state regulations. The facility census was 54.
F 0812: The facility failed to ensure food items were labeled, dated, or discarded when appropriate, failed to maintain the kitchen range hood free of grease and debris, and failed to maintain the freezer at 0 degrees Fahrenheit. The facility census was 54.
Report Facts
Residents Affected: 4
Facility Census: 54
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 6
Date: Feb 7, 2020
Visit Reason
Annual inspection of Luther Manor Retirement & Nursing Center to assess compliance with federal and state regulations including abuse/neglect policies, food safety, infection control, and tuberculosis screening.
Findings
The facility failed to obtain Nurse Aide registry/background screenings for four new employees and did not perform annual tuberculosis screenings for seven residents. Food safety violations included unlabeled and undated food items, improper temperature maintenance, and inadequate cleaning of kitchen equipment.
Deficiencies (6)
F607 Develop/Implement Abuse/Neglect Policies: Facility failed to obtain Nurse Aide registry/background screenings for four new employees prior to employment.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to ensure food items were labeled, dated, or discarded when appropriate and failed to maintain proper temperatures in kitchen equipment.
A4085 Infection Control/Communicable Disease: Facility failed to perform annual tuberculosis screenings for seven residents and did not document screenings properly.
A7015 Food-Protected, Temp, Need to Contact DHSS: Facility failed to maintain food at required temperatures and protect food from contamination.
A7022 Frozen Food at Zero Degrees F or Below: Facility failed to keep frozen food at required temperature of zero degrees Fahrenheit or below.
A7057 Ventilation: Hoods, Clean, Filters Removable: Facility failed to properly clean and maintain kitchen ventilation hoods and filters.
Report Facts
Facility census: 54
Number of new employees without NA registry checks: 4
Number of residents without annual TB screening: 7
Inspection Report
Life Safety
Census: 54
Capacity: 64
Deficiencies: 6
Date: Feb 7, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain required fire safety measures including sprinkler system maintenance, fire drills, electrical wiring safety, emergency generator documentation, and oxygen cylinder storage. Deficiencies had the potential to affect residents in multiple smoke compartments.
Deficiencies (6)
K161: The facility failed to maintain sprinklered stories with approved automatic sprinkler systems, including unsealed holes in ceilings compromising fire barriers. This affected 30 residents in four of seven smoke compartments.
K353: The facility failed to maintain the sprinkler system free of lint and debris, affecting 54 residents in four of seven smoke compartments.
K712: The facility failed to conduct fire drills under varied conditions on all shifts, affecting all occupants in seven smoke compartments.
K911: The facility failed to maintain electrical wiring in compliance with the National Electrical Code, including uncovered junction boxes, affecting 39 residents in two smoke compartments.
K918: The facility failed to maintain complete monthly documentation for the emergency generator, affecting all occupants in seven smoke compartments.
K923: The facility failed to adequately secure oxygen cylinders in accordance with NFPA 99, affecting 17 residents in one smoke compartment.
Report Facts
Facility capacity: 64
Census: 54
Number of smoke compartments affected: 7
Number of residents affected by sprinkler deficiencies: 54
Number of residents affected by electrical wiring deficiency: 39
Number of residents affected by oxygen cylinder storage deficiency: 17
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Sep 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving a resident fall and alleged inadequate supervision and care.
Complaint Details
The complaint investigation was triggered by a resident fall on 9/5/19, where the resident rolled out of bed and sustained a fatal head injury. The violation was determined to be at an immediate jeopardy level initially, later lowered to Level D and then Level J. The facility implemented corrective actions during the onsite visit.
Findings
The facility failed to obtain ordered laboratory blood work for one resident and failed to provide adequate supervision and assistance to prevent a resident fall resulting in a head injury and death. The facility was found to have deficiencies related to care planning, supervision, and accident prevention.
Deficiencies (2)
F658: The facility failed to obtain ordered laboratory blood work for one resident, missing a PT/INR lab on 8/28/19, which was not drawn or followed up as required.
F689: The facility failed to provide adequate supervision and assistance to one dependent resident, resulting in a fall with head injury and subsequent death.
Report Facts
Resident census: 57
Deficiency severity level: 1
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 12
Date: Dec 6, 2018
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Luther Manor Retirement & Nursing Center following a survey completed on 12/06/2018. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility was found deficient in multiple areas including failure to provide proper notice before resident transfers and discharges, failure to notify the ombudsman, inadequate bed-hold policies, insufficient assistance with activities of daily living, improper catheter care, inadequate drug regimen reviews, and failure to ensure proper immunizations. The facility census was 53 at the time of the survey.
Deficiencies (12)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notice of transfer to residents and their representatives and failed to notify the ombudsman for two residents transferred to the hospital.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to notify residents or their representatives in writing of the bed-hold policy upon transfer to the hospital for two residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure four residents received necessary care to maintain personal hygiene and prevent body odor.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate catheter care and prevent urinary tract infections for two residents with urinary catheters.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to develop policies and procedures for monthly drug regimen reviews and failed to ensure two residents received appropriate medication review.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to follow recipes to prepare palatable food for residents on pureed and mechanical soft diets.
F883 Influenza and Pneumococcal Immunizations: The facility failed to ensure residents received education, vaccination, and documentation consistent with CDC guidelines for influenza and pneumococcal vaccines.
A4029 Communicable Disease-Employees: The facility failed to implement policies to ensure employees were screened and tested for tuberculosis as required.
A4075 Clean, Dry, Odor Free: The facility failed to ensure residents were clean, dry, and free of offensive body and mouth odors.
A4085 Infection Control/Communicable Disease: The facility failed to report communicable diseases and ensure infection control procedures to prevent spread of infection.
A5003 Foods-Nutritive Value/Flavor/Appearance: The facility failed to prepare and serve food that conserved nutritive value, flavor, and appearance.
A5004 Food Texture-Chewing Difficulty: The facility failed to provide special attention to food texture for residents with chewing difficulties.
Report Facts
Facility census: 53
Residents sampled: 14
Residents with urinary catheters: 5
Residents with identified deficiencies: 2
Inspection Report
Life Safety
Census: 53
Capacity: 64
Deficiencies: 17
Date: Dec 6, 2018
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey for Luther Manor Retirement & Nursing Center.
Findings
Deficiencies were cited related to emergency preparedness exercises, hazardous areas enclosure, fire safety equipment, smoke barriers, smoking regulations, electrical systems, and oxygen storage. The facility failed to meet several NFPA and state fire safety requirements.
Deficiencies (17)
E039 Emergency Preparedness Testing Requirements were not met as the facility failed to conduct the required exercises to test the emergency plan at least annually, including a second full-scale exercise or tabletop meeting.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors protecting hazardous areas were self-closing and not propped open, potentially affecting residents and staff.
K324 Cooking Facilities: The facility failed to ensure range hood fire suppression nozzles were properly aimed to provide adequate coverage, creating potential fire hazards.
K372 Smoke Barrier Construction: The facility failed to maintain complete smoke barrier walls, allowing passage of smoke and fire through unsealed penetrations and openings.
K741 Smoking Regulations: The facility failed to ensure designated smoking areas were equipped with safe ashtrays and properly maintained, posing fire risks.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency generator with complete monthly documentation and testing, risking power failure during emergencies.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit use of extension cords and power strips beyond temporary installation, creating fire hazards.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to adequately separate and label oxygen tanks, risking confusion and fire hazards.
A2003 No Fire Hazard: The facility failed to ensure the furnace room was not used for storage of combustibles, creating a fire hazard affecting 32 residents.
A2008 Hazardous Areas: The facility failed to separate hazardous areas by fire-resistant construction and ensure doors were self-closing or automatic closing.
A2010 Oxygen Storage: The facility failed to use permanent racks or fasteners to prevent accidental damage or dislocation of oxygen cylinders.
A2017 Range Hood Certification: The facility failed to provide every cooking range with an approved range hood extinguishing system tested at least twice annually.
A2054 Smoke Section Walls/Doors: The facility failed to maintain continuous one-hour fire-rated smoke section walls and doors.
A2057 Ashtrays Noncombustibles/Safe Disposal: The facility failed to properly dispose of ashtrays of noncombustible material in designated smoking areas.
A2058 Fire Drill/Emergency Preparedness Plans: The facility failed to request or document consultation with the local fire department regarding emergency evacuation plans.
A3001 Substantially Constructed/Maintained: The facility failed to maintain the building in good repair according to construction standards.
A3030 Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
Report Facts
Facility census: 53
Facility capacity: 64
Residents potentially affected: 32
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 1
Date: Oct 2, 2018
Visit Reason
The document is a statement of deficiencies and plan of correction following a survey conducted on 10/02/2018 at Luther Manor Retirement & Nursing Center. The visit was related to regulatory compliance concerning resident safety and care.
Findings
The facility failed to provide adequate monitoring and evaluation of fall interventions for a resident who fell multiple times, resulting in serious injuries. Documentation and care plan updates related to fall interventions were lacking.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or assistance devices to prevent falls. The resident fell multiple times, sustaining serious injuries including fractures and contusions.
Report Facts
Facility census: 53
Number of falls: 15
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