Luther Acres Manor

Based on clincal record review, faciltiy policy review, observations and staff and resident interviews, it was determined that the facility failed to ensure that call bells were answered in a timely manner for one resident observed (Resident 1).Findings include: During interview conducted with Resident 1 on April 14, 2026, at 11:12 a.m., the resident stated he/she had concerns with the length of time it takes for staff to respond to his/her call bell. Resident 1 stated that he/she required assistance with incontinence care and had initiated his/her call bell at approximately 11:00 a.m. A staff member, who Resident 1 later identified as dietary staff, knocked on the resident's door at 11:17 a.m. to inquire if Resident 1 needed assistance because his/her call bell was on. Resident 1 stated he/she needed assistance with incontinence care, the staff member stated he/she would inform the nurse aide. At 11:35 a.m. when this Surveyor left the resident's room no staff had come to assist the resident. Observations made from the unit's nurses station until 12:03 p.m. revealed no staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, faciltiy policy review, observations and staff and resident interviews, it was determined that the facility failed to ensure that activities of daily living were performed in a timely manner for one resident observed (Resident 1)Findings include: Facility policy titled Activities of Daily Living (ADL), Supporting, last revised April 2025, documents residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (adls). Residents who are unable to carry out adls independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 1's Quarterly Minimum Data Set (MDS) dated [DATE], under the section for Activities of Daily Living (ADLs), revealed the resident requires a Hoyer lift and is dependent on staff assistance with showering/bathing, and toileting.During interview conducted with Resident 1 on April 14, 2026, at 11:12 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of observations and resident and staff interviews it was determined that the facility failed to provide activity of daily living (ADL) assistance for ten of eighteen residents (Residents R1, R3, R4, R5, R6, R7, R8, R9, R10, and R11).Findings include: During an observation on 8/7/25, at 10:38 a.m. when asked if she needed to wait an extended amount of time when she requests assistance with care, Resident R3 stated, Frequently on third shift. During an observation on 8/7/25, at 10:42 a.m. when asked if she needed to wait an extended amount to time when she requests assistance with care, Resident R4 stated, Depends on the aide. If we have agency people, then we wait. During an observation on 8/7/25, at 10:57 a.m. when asked if she felt the facility maintained an adequate number of staff, Resident R1 stated, Yes and no. I don't think there are enough of them in the evening. During an observation on 8/7/25, at 12:08 p.m. when asked if he needed to wait an extended amount to time when she requests assistance with care, Resident R4 stated, It takes a long time to get back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the wounds for two of six residents (Resident R1 and R2). Findings Include: Review of the facility policy General Wound Management dated 7/22/25, indicated, Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/24/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's order dated 7/25/25, indicated, Cleanse RLE (right lower extremity) skin tear with NSS (normal saline solution), apply calcium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from physical restraints (Resident 1). Findings include: Review of facility policy, Restraint Policy, undated, revealed: restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions: 1) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2) with a physician order; 3) with the consent of the resident or legal representative; 4) when the benefits of the restraint outweigh the identified risks. Review of facility orientation packet given to outside nursing staff and nursing students revealed: This is a restraint free facility. Review of nurse aide Employee E5's orientation packet revealed the employee signed acknowledgement of receipt and understanding of the orientation materials on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews it was determined that the facility failed to ensure a resident's code status for one out of 24 residents reviewed (Resident 71). Findings include: Review of the clinical record revealed Resident 71 was admitted to the facility on [DATE]. Review of Resident 71's clinical record revealed a POLST (Pennsylvania -Orders for Life Sustaining Treatment), signed on February 7, 2023, indicating the resident wanted life sustaining code status to be considered, Do Not Resuscitate (DNR). Review of the physician orders revealed the DNR was not current. Interview with the Social Service Director, Employee E3 December 7, 2023 at 10:30 a.m., confirmed the DNR order was not listed on the residents physician orders as Resident 71 intended as stated on the POLST form. The facility failed to ensure the resident's right to formulate an advance directive for Resident 71. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical records review and staff interview, it was determined that the facility failed to investigate an allegation of being rough during care for one of the 18 residents reviewed (Resident 8). Findings include: Review of Resident 8's diagnosis list includes Traumatic Brain Injury (TBI), and Anxiety (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated September 14, 2023, revealed resident had moderate impairment with cognition and required extensive assistance with personal hygiene and dressing. Review of Resident 28's nursing progress notes dated October 16, 2023, at 2:56 p.m., revealed Resident 8 told the aide assisting her/him that she/he was being too rough. Another aide came to assist the resident then pulled the second aide's hair and said, Was that soft and gentle? Interview was conducted with the Director of Nursing (DON) on December 14, 2023, at 10:00 a.m. The DON reported a second aide came to assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to follow physician orders for the administration of insulin for one of two residents reviewed (Resident 64). Findings include: Review of facility policy and procedure titled Insulin Administration, revised February 2015 revealed Check blood glucose per physician order or nursing protocol. Review of Resident 64's diagnosis list revealed diagnoses including Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident 64's physician orders revealed an order to check glucose with Libre 2 system three times per day before meals. Further review of Resident 64's physician orders revealed an order for Novolog Insulin, Inject 10 units twice daily morning and afternoon with meals. Hold for blood sugar less than 150 and to inject 5 units every evening with meals. Hold for blood sugar less than 150. Review of Resident 64's November 2023 Medication Administration Record (MAR) revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to ensure a thorough investigation was completed for injuries of unknown origin for 2 of 18 residents reviewed (Resident 15 and Resident 28). Findings include: Review of facility policy and procedure titled Accident, Incident and Death Reporting/Investigation, revised 2019, revealed Any injury should be classified as an 'injury of unknown origin' when the following conditions are met: a) the origin of the injury was not observed by any person or the origin of the injury could not be explained by the resident; b) the injury is suspicious because of the extent of the injury, or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma such as, but not limited to breast or groin area), or the number of injuries observed at one particular point in time (such as multiple bruises in a pattern resembling finger marks), or the incidence of the injuries over time and c) there is no reasonable determination as to how the injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.