Pennsylvania Department of Health
LUTHER ACRES MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LUTHER ACRES MANOR
Inspection Results For:

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LUTHER ACRES MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on February 27,2026 it was determined that Luther Acres Manor was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the Health portion of the survey process.

Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of clinical records, observation and staff interview, the facility failed to maintain enhanced barrier precautions for three out of 18 residents reviewed (Residents 10, 11, and 21).

Findings include:

A review of facility policy entitled "Enhanced Barrier Precautions", revised May 29. 2024 revealed: "EBP (Enhanced Barrier Precautions - an infection control intervention to reduce transmission of multi-drug-resistant organisms (MDRO) that requires gown and glove use during high contact resident activities) are indicated for residents with any of the following:
Infection or colonization (the presence of organisms without causing harm) with a CDC-targeted MDRO (organisms that are of significant concern to the Centers for Disease Control due to their resistance to multiple antibiotics and potential for spread)Wounds generally include wounds that are chronic and require prolonged healing time.Indwelling medical devices such as...central lines (a flexible tube placed into a large vein that provides access to the central circulation near the heart), midlines (a flexible tube placed into the vein of the upper arm), urinary catheters (a tube placed in the bladder to drain urine).To maintain a homelike environment, residents requiring EBP will have a magnet outside of their door and appropriate signage inside the room indicating what PPE (Personal Protective Equipment such as gowns, gloves, face shields) is required. PPE and alcohol-based hand rub will be readily available for staff use when caring for residents requiring EBP."

Review of Resident 10's care plan revealed a care plan for EBP "to reduce the spread of MDRO's related to chronic heel wounds and permacath (a type of central line) to right chest."

Observation of Resident 10's room at approximately 1:45PM revealed an EBP magnet on the frame of the door, and signage in the bathroom, but no gowns in the room.

Review of resident 11's care plan revealed a care plan for EBP "to reduce the spread of MDRO's related to urinary...catheter."

Observation of Resident 11's room at approximately 1:30PM revealed an EBP magnet on the frame of the door, no signage in the room and no gowns in the room.

The DON confirmed this observation on February 26, 2026, at approximately 1:35PM.

Review of Resident 21's care plan revealed a care plan for EBP "to reduce the spread of MDRO's related to chronic wound on scalp."

Observation of Resident 21's room on February 25, 2026 at approximately 1:50PM revealed an EBP magnet on the door frame, no signage inside the room, and no gowns inside the room.

Interview with Infection Preventionist on February 25, 2026, at approximately 1:30PM revealed that for residents on EBP, magnets are placed on the door frame facing the hallway, signage indicating the type of PPE required is inside the room, either on the back of the hall door or the back of the bathroom door, and PPE is in the bathroom.

Interview with the Director of Nursing on February 27, 2026, at approximately 2:45PM confirmed that for residents with EBP, PPE and signage should be in the resident's room.

28 Pa. Code 211.12(d)(1)(3)(5)Nursing services

Plan of Correction - To be completed: 04/24/2026

Facility wide audit will be completed for all residents on EBP to ensure proper signage and PPE is present.

All nursing staff and IDT will be educated on EBP policy/procedure.

DON/Designee will complete random daily audits x30 days of residents on EBP to ensure proper signage and PPE is present.

DON/Designee will report findings to QAPI for review and recommendations regarding need for continued audits.

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 04/24/2026

Physician has been notified of Resident 35's blood pressures that were out of parameter.

Physician has been notified of Resident 76's weight gains.

Facility wide audit will be conducted to identify any residents with blood pressure parameters.

Facility wide audit will be conducted to identify all residents ordered daily weights.

Findings of blood pressure parameter audits will be reviewed with Physician to determine if parameters are appropriate/necessary.

Findings of daily weight order audit will be be reviewed with Physician to determine if parameters are appropriate/necessary.

Licensed staff will be educated on Physician notification related to blood pressure medication parameters.

Licensed staff will be educated on Physician notification related to daily weight orders with parameters.

DON/Designee will complete audits of new orders for blood pressure medications weekly x4 to ensure proper supplementary documentation is present on blood pressure medication order.

Dietician/Designee will complete daily audits of Physician notifications related to daily weight parameters x30 days.

DON/Designee will report findings to QAPI for review and recommendations regarding the need for continued audits.

Dietician/Designee will report findings to QAPI for review and recommendations regarding the need for continued audits.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that pressure ulcer was assessed and monitored for one of three residents reviewed (Resident 3).

Findings Include:

Review of the facility's policy titled "General Wound Management" last reviewed February 10, 2020, stated that 'Ongoing Wound Assessment... the wound nurse us responsible for coordinating, preparing and maintaining the functioning of the wound round team ...3. Comprehensive wound assessment should include at least the following parameters: Location of wound which may provide information related to the etiology of the wound; b. Length , width and depth measurements recorded in centimeters; c. Direction and length of tunneling and undermining; d. Appearance of the wound base; e. Type and percentage of tissue in wound; f. Drainage amount and characteristics including color, consistency and odor.'

Review of Resident 3 physician orders revealed an order started on January 28, 2026 "Wash wound with soap and water scrubbing gently. Rinse well and pat dry. Irrigate well with NSS (Normal Saline Solution- sterile salt water). Pack tunnel at 12o'clock (top) and undermining (occurs when tissue destruction extends beneath the skin edges, creating a hidden pocket or shelf around the margin) from 9 o'clock to 3o'clock (left to right) with white granufoam (black foam placed inside the wound). Place black foam to fill the rest of wound and assist in bridging to side of patient. Set Wound vac (a therapeutic device using controlled suction to promote healing in chronic or severe wounds) at 150mmhg (millimeters of mercury) continuous negative pressure with granufoam to wound. Place drape around edges to protect May use stoma paste (adhesive safe on skin)or alginateperi wound for seal or skin irritation (adhesive safe on skin) one time a day every Mon, Wed, Fri for Wound care AND as needed for Wound care."

Review of Resident 3's Treatment Administration Records for December 2025, January 2026 and February 2026 revealed that treatment was provided as per order.

Review of Resident 3's clinical record did not include facility documentation of the wound weekly assessments, measurements or monitoring in December 2025, January 2026 and February 2026.

Interview with the Director of Nursing on February 27,2026 at 2:30 pm confirmed the above findings.

28 Pa. Code: 211.5 (f) Clinical records

28 Pa. Code: 211.12 (d) (1) (5) Nursing Services

Plan of Correction - To be completed: 04/24/2026

Resident 3's wound is being assessed weekly.

Facility wide skin sweep completed on all residents.

Facility wide audit will be completed for all residents with current wounds to ensure treatments are being provided as ordered.

Licensed staff will be educated on weekly wound documentation.

DON/Designee will complete weekly random audits of wound assessments to ensure completion x4 weeks.

DON/Designee will complete weekly random audits of wound treatments to ensure they are being provided as ordered x4 weeks.

DON/Designee will report findings to QAPI for review and recommendations for the need for continued audits.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for one of one dialysis resident reviewed. (Resident 10).

Findings include:

A review of the facility's policy titled "Fluid Monitoring", dated 11/05/2019, revealed the following guidelines for restricting fluids: "f. Dietician/ Designee is responsible for ensuring the total I/Os for the day, which are recorded in the EMAR. ... g. Breakdown of fluids for med pass is determined by dietician/designee and placed on EMAR"

Review of Resident 10's diagnosis list includes End Stage Renal Failure (ESRD- failure of kidney function to remove toxins from blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).

Review of Resident physician's orders revealed orders for Fluid restriction: 1500ml Fluid Restriction: 7-3 provide 840ml (360ml at breakfast, 240ml at lunch, 240ml at medpass); 1500ml Fluid Restriction: 3-11 provide 540ml (300ml at dinner, 240ml at med pass) every evening shift dated November 10 2025 and 1500ml Fluid Restriction: 11-7 provide 120ml every night shift dated November 9 2025.

Review of Resident 10's Medical Administration Record (MAR) failed to reveal evidence of the amount of fluid Resident 10 was receiving each shift.

Interview with Director of Nursing on February 27, 2026, at approximately 11:30am confirmed the above findings.

28 Pa. Code: 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(5) Nursing Service

Plan of Correction - To be completed: 04/24/2026

Resident 10's fluid restriction order has been updated with supplementary documentation.

Facility wide audit will be conducted for all residents ordered a fluid restriction.

Fluid restriction orders will be updated to include supplementary documentation that reflects the amount of fluids received by resident each shift.

Licensed staff will be educated on MAR/supplementary documentation related to amount of fluids received by resident each shift.

Dietician/Designee will complete daily audits x30 days to ensure fluids received by resident each shift are being properly recorded in MAR for residents ordered a fluid restriction.

Dietician/Designee will report findings to QAPI for review and recommendations regarding the need for continued audits.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based upon clinical record review and staff interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon for one of five residents reviewed (Resident 9).

Findings include:

Review of Resident 9's Pharmacy Regime Review performed between November 1, 2025, and November 30, 2025, revealed a recommendation for PRN (as needed) pain medication Naproxen (a non-steroidal anti-inflammatory medication used to treat pain) to be specifically staged for use according to pain severity, for example, Naproxen 250 mg (milligrams) for prn mild pain, Naproxen 500 mg prn for moderate to severe pain. The physician agreed with and signed the recommendation.

Review of Resident 9's physician orders revealed an order for Naproxen Oral Tablet 500 mg, give 2 tablets by mouth every 6 hours as needed for pain with a start date of August 11, 2025.

Review of Resident 9's December 2025, January 2026 and February 2026, Medication Administration Reports (MAR) revealed an order for Naproxen Oral Tablet 500 mg, give 2 tablets by mouth every 6 hours as needed for pain with a start date of August 11, 2025.

Review of Resident 9's physician orders failed to reveal that the resident's orders were updated to reflect the above pharmacy recommendation.

Interview conducted with the Director of Nursing (DON) on February 26, 2026, at 1:30 p.m., when the above information was presented, the DON confirmed the resident's physician orders had not been updated to reflect the pharmacist's recommendations.

483.45 Drug Regimen Review, Report Irregular, Act on

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 04/24/2026

Resident 9's order for Naproxen has been updated to reflect Pharmacy recommendations.

DON/Designee will audit December, January and February Pharmacy recommendations to ensure follow up was completed.

DON has completed educations with Licensed Staff regarding Pharmacy recommendation follow up process.

DON/Designee will audit Pharmacy recommendations monthly to ensure proper follow up was completed.

DON/Designee will report findings to QAPI for review and recommendations regarding need for continued audits.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based upon clinical record review and interview, it was determined the facility failed to ensure non-pharmaceutical interventions were completed prior to the administration of pain medication for one resident and failed to ensure side effects were monitored during the use of anti-psychotic medication for three out of 18 Residents. (Resident 39 and Resident 66 and Resident 75).

Findings include:

Review of facility policy titled "Psychotropic Medication Use" (psychotropic medications affect mood and behavior and are used to treat mental health conditions) revised April 20. 2021, revealed "Resident behaviors will be documented in the medical record as observed by staff, to include documentation in nurse's notes or other designated forms of non-pharmacological interventions (strategies to manage health conditions without medications) used."

Review of Resident 39's physician orders revealed orders for oxycodone 5mg tab; 1 tab by mouth at bedtime as needed for pain; an order for oxycodone 5mg tab 1/2 tablet (2.5mg) by mouth every 4 hours as needed for mod-severe pain discontinued February 12, 2026.
Review of Resident 39's January 2026 and February 2026 Medication Administration Record revealed Resident 39 received Oxycodone 5mg on the following dates: January 3 2026, January 4 2026, January 5 2026 January 7 2026, January 8 2026, January 9 2026, January 10 2026, January 11 2026, January 12 2026, January 13 2026, January14 2026, January 15 2026, January16 2026 , January17 2026, January 18 2026, January19 2026, January 21 2026, January 23 2026 and January 24 2026; received Oxycodone 10 mg on February 20,2026.

Further review of Resident 39's clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of Oxycodone 10 mg.

Interview with the Director of Nursing on February 27, 2026, at 1:30 p.m. confirmed that non-pharmaceutical interventions were not attempted prior to the administration of Resident 39's pain medication.

Review of Resident 66's January 2026 and February 2026 Medication Administration Record revealed an order for Quetiapine (an antipsychotic medication used to regulate mood or behavior) 25MG once daily at bedtime for unspecified dementia, unspecified severity with other behavioral disturbance, dated January 22, 2026, with no order for side-effect monitoring.

Review of Resident 75's January 2026 and February 2026 Medication Administration Record revealed an order for Quetiapine 25MG twice a day for major depressive disorder, recurrent, unspecified dated January 21, 2026, with no order for side-effect monitoring.

Review of Resident 66 and 75's clinical record revealed there was no evidence the facility was monitoring the residents for side effects of psychotropic medication or monitoring the residents' behaviors for the effectiveness of the medications.

Interview with the Director of Nursing on February 27, 2026, at approximately 1:20PM confirmed that residents 66 and 75 did not have orders to monitor and document the side effects in the resident's chart.

28 Pa. Code 211.12(d)(1)(5) Nursing Services

Plan of Correction - To be completed: 04/24/2026

Resident 39's Oxycodone order has been updated to include non-pharmaceutical interventions to be attempted prior to medication administration.

Resident 66 and Resident 75's orders have been updated to include Psychotropic Medication side effect monitoring.

Facility wide audit will be completed on all PRN pain medication orders. Non-pharmaceutical interventions to be attempted prior to medication administration will be added to orders.

Facility wide audit will be completed for residents ordered a psychotropic medication. Orders will be updated to include side effect monitoring.

Licensed staff will be educated on need to complete non-pharmaceutical interventions prior to administration of PRN pain medications.

Licensed staff will be educated on need to monitor side effects when a resident is ordered a psychotropic medication.

DON/Designee will complete random audits of PRN pain medication administration records weekly x4 to ensure to non-pharmaceutical interventions are completed prior to administration of PRN pain medications.

DON/Designee will complete an audits of new orders for psychotropic medications weekly x4 to ensure side effect monitoring is present.

DON/Designee will report findings to QAPI for review and recommendations in regards to need for continued audits.

DON/Designee will report findings to QAPI for review and recommendations regarding the need for continued audits.

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