Luther Manor

Penalties

• Sep 10, 2024 — Fine ($103,705)
• Sep 10, 2024 — Payment Denial · payment denial 53 days
• Jun 11, 2024 — Fine ($34,468)
• Feb 1, 2024 — Fine ($25,454)
• Feb 1, 2024 — Payment Denial · payment denial 14 days

Inspection findings

1. Jan 14, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Feb 16, 2026 · CMS health inspection

2. Dec 16, 2025 Health · 16 findings
   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Jan 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jan 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Jan 17, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jan 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 28, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jan 30, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Jan 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jan 17, 2026 · CMS fire safety

3. Jul 29, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 21, 2025 · CMS health inspection

4. May 13, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected May 31, 2025 · CMS health inspection

5. Mar 26, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 27, 2025 · CMS health inspection

6. Oct 31, 2024 Health · 9 findings
   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Nov 25, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Nov 25, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0660 Resident Assessment and Care Planning Deficiencies

     Plan the resident's discharge to meet the resident's goals and needs.

     Corrected Dec 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0745 Quality of Life and Care Deficiencies

     Provide medically-related social services to help each resident achieve the highest possible quality of life.

     Corrected Nov 29, 2024 · CMS health inspection

7. Sep 10, 2024 Fire Safety · 25 findings
   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Oct 7, 2024 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Nov 20, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 8, 2024 · CMS health inspection

   • Serious Scope/severity J

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Sep 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Sep 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Sep 12, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Sep 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Sep 25, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Sep 18, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 8, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Sep 17, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 17, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0791 Miscellaneous Deficiencies

     Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.

     Corrected Sep 12, 2024 · CMS fire safety

8. Jun 11, 2024 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 3, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 3, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 3, 2024 · CMS health inspection

9. Feb 1, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Feb 6, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 4, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 14, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 14, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Mar 4, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 4, 2024 · CMS health inspection

10. Jul 27, 2023 Health · 18 findings
    • Not serious Scope/severity D

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Aug 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Aug 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0623 Resident Rights Deficiencies

      Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

      Corrected Aug 23, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0625 Resident Rights Deficiencies

      Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

      Corrected Aug 23, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0742 Quality of Life and Care Deficiencies

      Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

      Corrected Aug 25, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Aug 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Aug 25, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0132 Construction Deficiencies

      Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

      Corrected Sep 29, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0271 Egress Deficiencies

      Have exits that are accessible at all times.

      Corrected Aug 25, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0291 Egress Deficiencies

      Install emergency lighting that can last at least 1 1/2 hours.

      Corrected Aug 23, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0293 Egress Deficiencies

      Have properly located and lighted "Exit" signs.

      Corrected Aug 25, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Aug 25, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Aug 25, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0362 Smoke Deficiencies

      Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

      Corrected Dec 15, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Aug 25, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Aug 23, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Sep 15, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected Aug 25, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CHEDID, STEPHANIE — corporate officer, NOT APPLICABLE, since 02/18/2015
• CHEDID, STEPHANIE — adp of the snf, NOT APPLICABLE, since 02/18/2015
• COOPER, DELILA — adp of the snf, NOT APPLICABLE, since 04/15/2024
• COOPER, DELILA — operational/managerial control, NOT APPLICABLE, since 04/15/2024
• GIBBS, KAREN — adp of the snf, NOT APPLICABLE, since 09/27/2021
• GIBBS, KAREN — operational/managerial control, NOT APPLICABLE, since 09/27/2021
• HANSEN, PATRICK — corporate officer, NOT APPLICABLE, since 08/14/2017
• HANSEN, PATRICK — adp of the snf, NOT APPLICABLE, since 08/14/2017
• HANSEN, PATRICK — operational/managerial control, NOT APPLICABLE, since 08/14/2017
• JUNG, KIM — adp of the snf, NOT APPLICABLE, since 12/09/2024
• JUNG, KIM — operational/managerial control, NOT APPLICABLE, since 12/09/2024
• KEUP, ARTHUR — adp of the snf, NOT APPLICABLE, since 11/13/2017
• KEUP, ARTHUR — corporate officer, NOT APPLICABLE, since 11/13/2017
• SELECT REHABILITATION, LLC — adp of the snf, NOT APPLICABLE, since 01/24/2025
• SELECT REHABILITATION, LLC — operational/managerial control, NOT APPLICABLE, since 01/24/2025
• SODEXO AMERICA, LLC — operational/managerial control, NOT APPLICABLE, since 01/24/2025
• SODEXO AMERICA, LLC — adp of the snf, NOT APPLICABLE, since 01/24/2025
• UNITED LUTHERAN PROGRAM FOR THE AGING, INC — adp of the snf, NOT APPLICABLE, since 01/24/2025
• UNITED LUTHERAN PROGRAM FOR THE AGING, INC — operational/managerial control, NOT APPLICABLE, since 01/24/2025
• UNITED LUTHERAN PROGRAM FOR THE AGING, INC — direct ownership interest, NOT APPLICABLE, since 01/01/1966