Inspection Reports for
Luther Memorial Home
30, 34, 36 8th Ave SE, Mayville, ND, 58257
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 31, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards including resident assessment accuracy, food service sanitation, and infection prevention and control.
Findings
The facility was found deficient in accurately coding resident assessments, proper glove use during food service, and adherence to infection control practices, all posing minimal harm or potential for harm to residents.
Deficiencies (3)
Failure to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents, affecting the accuracy of resident assessments and care planning.
Failure to ensure proper glove usage when serving food in 1 of 1 kitchen, risking foodborne illness.
Failure to follow infection control practices regarding hand hygiene during cares for 1 of 6 sampled residents, risking transmission of infections.
Report Facts
Residents sampled: 17
Residents sampled: 6
Kitchens inspected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#2) | Confirmed incorrect coding of Resident #10's MDS | |
| Dietary Manager (#1) | Confirmed dietary staff failed to change gloves before handling food | |
| Certified Nurse Aide (#3) | Observed failing to perform hand hygiene after glove removal during resident care | |
| Infection Control Nurse (#2) | Stated expectation for hand hygiene after glove removal |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments and infection prevention and control practices.
Findings
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, affecting the resident's assessment and care planning. Additionally, the facility failed to implement proper infection prevention and control measures for one resident on enhanced barrier precautions, risking potential infection spread.
Deficiencies (2)
Failure to ensure accurate coding of the Minimum Data Set (MDS) for one resident, resulting in inaccurate resident assessment.
Failure to provide and implement an infection prevention and control program, specifically failure to follow enhanced barrier precautions for one resident.
Report Facts
Sampled residents for MDS coding: 15
Sampled residents for infection control: 5
Quarterly MDS dates: Two quarterly MDSs dated 06/21/24 and 09/21/24 reviewed for Resident #49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Confirmed staff failed to code the MDS correctly for Resident #49 | |
| Certified Nurse Aide (CNA) | Observed not following enhanced barrier precautions during resident care | |
| Administrative Nurse | Stated expectation for signage, PPE availability, and staff compliance with infection control policy |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and infection prevention and control practices at Luther Memorial Home.
Findings
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, affecting the resident's assessment and care planning. Additionally, the facility did not follow infection control standards for one resident on enhanced barrier precautions, risking potential infection spread.
Deficiencies (2)
Failure to ensure accurate coding of the Minimum Data Set (MDS) for one resident, resulting in inaccurate resident assessment.
Failure to provide and implement an infection prevention and control program, specifically not following enhanced barrier precautions for one resident.
Report Facts
Sampled residents for MDS coding: 15
Sampled residents for infection control: 5
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Confirmed staff failed to code the MDS correctly for Resident #49 | |
| Certified Nurse Aide (CNA) | Observed not following enhanced barrier precautions during resident care | |
| Administrative Nurse | Stated expectation for signage, PPE availability, and policy adherence |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 5, 2024
Visit Reason
The inspection was conducted as a complaint survey triggered by concerns about the facility's failure to provide appropriate care and treatment for a resident with diabetes, specifically related to blood glucose monitoring and management.
Complaint Details
The complaint investigation found an Immediate Jeopardy situation on 02/01/24 due to failure to properly monitor and treat low blood glucose in Resident #1, resulting in the resident being found unresponsive and deceased. The facility submitted and implemented a removal plan for the Immediate Jeopardy, which was accepted by the State Survey Agency.
Findings
The facility failed to provide care according to professional standards for Resident #1 with diabetes, resulting in an Immediate Jeopardy due to staff not rechecking blood glucose or taking appropriate interventions after a low blood sugar reading. The resident was found unresponsive and could not be revived. Multiple documentation and procedural failures were identified, including delayed medication administration, lack of timely progress notes, and failure to provide bedtime snacks when indicated.
Deficiencies (7)
Failure to recheck blood glucoses after 15 minutes when blood glucose is below 70 mg/dL.
Failure to document interventions for low blood glucoses or between 70 mg/dL and 120 mg/dL at bedtime.
Failure to complete 8:00 p.m. orders in a timely manner.
Failure to document the times staff obtained blood sugars of 83 mg/dL and 61 mg/dL.
Failure to assess the resident following an emesis event.
Failure to create a progress note in a timely manner; progress note created over 33 hours later.
Failure to provide a bedtime snack when blood sugars were between 70 mg/dL and 120 mg/dL.
Report Facts
Blood glucose readings: 61
Blood glucose readings: 83
Insulin dosage: 30
Insulin dosage: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse | Nurse (#1) administered insulin and documented blood sugar checks late; failed to recheck blood sugar and document times | |
| Certified Nurse Aide (CNA) | CNA (#3) provided cranberry juice and honey to Resident #1 as instructed | |
| Director of Nursing (DON) | Received notification of Immediate Jeopardy and submitted removal plan | |
| Administrator | Notified of Immediate Jeopardy situation |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with safety and care standards, specifically regarding accident hazards and supervision to prevent accidents involving residents.
Findings
The facility failed to ensure an environment free of accident hazards and adequate supervision for two residents: one who spilled hot liquid and another who smoked cigarettes without proper assessment or interventions. The facility lacked policies on hot liquid spills and tobacco use assessments.
Deficiencies (1)
Failure to provide a policy regarding hot liquid spills and completing smoking assessments.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| dietary manager | Interviewed regarding lack of interventions after hot liquid spill | |
| licensed nurse | Verified hot liquid spill incident | |
| administrative nurse | Confirmed failure to implement interventions and lack of tobacco use assessment | |
| staff member | Described smoking procedures and resident sign-in/out |
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