Inspection visit
Health inspection
Citations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
FAQ · About this visit
Common questions about this visit
What happened during the September 10, 2024 survey of LUTHER MANOR?
This was a inspection survey of LUTHER MANOR on September 10, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHER MANOR on September 10, 2024?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.