LUTHER MANOR RETIREMENT & NURSING CENTER

Nursing Home Inspector

3170 HIGHWAY 61 NORTH
HANNIBAL, MO 63401
Marion County
Phone: 573-221-5533
Provider Number: 265690
Last Inspection: 09/14/2017

About the Nursing Home

Number of Beds: 64
Number of Residents: 46
Beds Available: 18
Percent Occupancy: 72%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

28

Facility
25

County
21

MO
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

28

2017
37

2016
31

2016

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/14/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 10/20/2017
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 10/20/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/20/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/20/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 10/20/2017
 
Failed To: Maintain 15 months of resident assessments in the resident's active clinical record. Widespread : Potential 4 10/20/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 10/20/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 10/20/2017
 

12/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Potential 3 1/20/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 1/20/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 1/20/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 1/20/2017
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 1/20/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/20/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 1/20/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/20/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 1/20/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/20/2017
 

1/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Potential 3 2/29/2016
 
Failed To: Try to resolve each resident's complaints quickly. Pattern : Minimal 4 2/29/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 2/29/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Pattern : Minimal 4 2/29/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/29/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 3/22/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 2/29/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/29/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/14/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 6/5/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MO State Avg
Number of Residents 46 81.17 74.26
Registered Nurses 0.72 0.51 0.60
Licensed Practical / Vocational Nurses 0.98 0.86 0.72
Certified Nursing Assistants 2.65 2.04 2.43
Total Staff Hours 4.35 3.41 3.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MO State Avg%
of high risk long-stay residents with pressure ulcers 5 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 83 95 88
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 87 95 93
of long-stay residents experiencing one or more falls with major injury 6 5 4
of long-stay residents who have depressive symptoms 7 3 3
of long-stay residents who lose too much weight 11 9 7
of long-stay residents who received an antianxiety or hypnotic medication 19 19 26
of long-stay residents who received an antipsychotic medication 2 22 18
of long-stay residents who self-report moderate to severe pain 8 7 7
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 32 17 15
of long-stay residents whose need for help with daily activities has increased 28 16 14
of long-stay residents with a catheter inserted and left in their bladder 4 2 2
of long-stay residents with a urinary tract infection 2 4 4
of low risk long-stay residents who lose control of their bowels or bladder 35 35 32
of short-stay residents assessed and appropriately given the pneumococcal vaccine 33 78 74
of short-stay residents who had an outpatient emergency department visit 7 9 12
of short-stay residents who made improvements in function 77 79 68
of short-stay residents who newly received an antipsychotic medication 5 7 2
of short-stay residents who self-report moderate to severe pain 23 17 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 43 76 73
of short-stay residents who were rehospitalized after a nursing home admission 16 18 22
of short-stay residents who were successfully discharged to the community 55 55 50
of short-stay residents with pressure ulcers that are new or worsened 4 2 1