Pennsylvania Department of Health
 LUTHER WOODS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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LUTHER WOODS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  116 surveys for this facility. Please select a date to view the survey results.

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LUTHER WOODS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on May 23, 2025, at Luther Woods Nursing and Rehabilitation Center, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility did not ensure a minimum of one nurse aide (NA) for every 12 residents on the day shift for five of 21 days reviewed, one NA for every 12 residents on the evening shift for five of 21 days reviewed, and one NA for every 20 residents during the night shift on 13 of 21 days reviewed. (April 26, 2025 through May 12, 2025)

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the resident census:

Day shift (requires one NA per 12 residents)
May 1, 2025, 11.03 NAs, with a census of 134 residents, required 13.40 NAs.
May 5, 2025, 12.10 NAs, with a census of 137 residents, required 13.40 NAs.
May 6, 2025, 13.40 NAs, with a census of 134 residents, required 13.17 NAs.
May 11, 2025, 13.07 NAs, with a census of 137 residents, required 13.70 NAs.
May 12, 2025, 13.57 NAs, with a census of 136 residents, required 13.60 NAs.

Evening shift (requires one NA per 12 residents)
April 28, 2025, 3.13 NAs, with a census of 132 residents, required 5.28 NAs.
April 30, 2025, 12.00 NAs, with a census of 133 residents, required 12.09 NAs.
May 2, 2025, 10.97 NAs, with a census of 136 residents, required 12.36 NAs.
May 8, 2025, 9.90 Nas, with a census of 138 residents, required 74.25 NAs.
May 11, 2025, 11.90 NAs, with a census of 137 residents, required 12.45 NAs.

Night shift (requires one NA per 20 residents)
April 26, 2025, 7.17 NAs, with a census of 110 residents, required 8.87 NAs.
April 27, 2025, 4.27 NAs, with a census of 133 residents, required 8.87 NAs.
April 28, 2025, 4.27 NAs, with a census of 132 residents, required 8.80 NAs.
April 29, 2025, 6.17 NAs, with a census of 132 residents, required 8.80 NAs.
April 30, 2025, 8.03 NAs, with a census of 133 residents, required 8.87 NAs.
May 2, 2025, 6.13 NAs, with a census of 136 residents, required 9.07 NAs.
May 3, 2025, 6.17 NAs, with a census of 136 residents, required 9.07 Nas
May 4, 2025, 7.03 NAs, with a census of 135 residents, required 9.00 Nas
May 5, 2025, 6.13 NAs, with a census of 136 residents, required 9.07 Nas
May 6, 2025, 6.97 NAs, with a census of 134 residents, required 8.93 Nas
May 7, 2025, 6.23 NAs, with a census of 138 residents, required 9.20 NAs
May 8, 2025, 8.03 NAs, with a census of 138 residents, required 9.20 Nas
May 9, 2025, 7.03 NAs, with a census of 136 residents, required 9.07 NAs

Interview with the Nursing Home Administrator via electronic communications, on May 27, 2025, at 11:00 a.m., confirmed that the above staffing levels did not meet the required minimums.




 Plan of Correction - To be completed: 06/06/2025

Director of Nursing/Assistant Director of Nursing will conduct a random audit of 15 days throughout the quarter and findings will be reported quarterly at QAPI.
We have signage out front. We have ads thru Apploi/Indeed. We have sign on bonuses for both new hires and for staff that recommend anyone. We put flyers at area bus stops. We have had successful hires.
The Scheduler was reminded of the importance of maintaining a 3.2 HPPD or greater on a daily basis.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on review of nursing schedules and staff interview, it was determined that the facility administrative staff did not ensure to provide a minimum of one LPN (Licensed Practical Nurse) per 25 residents during day shift, a minimum of one LPN per 30 residents during evening shift, and a minimum of one LPN per 40 residents during night shift for 21 out of 21 days reviewed (April 2, 2025 through May 22, 2025).

Findings include:

Review of facility census data indicated that on April 26, 2025, the facility census was 133, which required 5.32 LPN's during day shift. Review of the nursing time schedules revealed 5.19 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 26, 2025, the facility census was 133, which required 4.43 LPN's during evening shift. Review of the nursing time schedules revealed 1.81 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 26, 2025, the facility census was 133, which required 8.87 LPN's during night shift. Review of the nursing time schedules revealed 7.17 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 27, 2025, the facility census was 133, which required 5.32 LPN's during day shift. Review of the nursing time schedules revealed 4.25 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 27, 2025, the facility census was 133, which required 4.43 LPN's during evening shift. Review of the nursing time schedules revealed 1.09 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 27, 2025, the facility census was 133, which required 8.87 LPN's during night shift. Review of the nursing time schedules revealed 4.27 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 28, 2025, the facility census was 132, which required 5.28 LPN's during day shift. Review of the nursing time schedules revealed 3.13 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 28, 2025, the facility census was 132, which required 4.40 LPN's during evening shift. Review of the nursing time schedules revealed 3.13 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 28, 2025, the facility census was 132, which required 3.09 LPN's during night shift. Review of the nursing time schedules revealed 3.30 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 29, 2025, the facility census was 132, which required 5.28 LPN's during day shift. Review of the nursing time schedules revealed 6.63 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 29, 2025, the facility census was 132, which required 4.40 LPN's during evening shift. Review of the nursing time schedules revealed 2.06 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 29, 2025, the facility census was 132, which required 3.30 LPN's during night shift. Review of the nursing time schedules revealed 2.13 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 30, 2025, the facility census was 133, which required 5.32 LPN's during day shift. Review of the nursing time schedules revealed 4.25 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 30, 2025, the facility census was 133, which required 4.43 LPN's during evening shift. Review of the nursing time schedules revealed 4.09 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 30, 2025, the facility census was 133, which required 3.33 LPN's during night shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 01, 2025, the facility census was 134, which required 4.47 LPN's during evening shift. Review of the nursing time schedules revealed 2.38LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 2, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 3.22 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 2, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.03 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 3, 2025, the facility census was 136, which required 5.44 LPN's during day shift. Review of the nursing time schedules revealed 5.16 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 3, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 1.97 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 4, 2025, the facility census was 135, which required 5.40 LPN's during day shift. Review of the nursing time schedules revealed 3.25 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 4, 2025, the facility census was 135, which required 4.50 LPN's during evening shift. Review of the nursing time schedules revealed 1.91 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 4, 2025, the facility census was 135, which required 3.38 LPN's during night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 5, 2025, the facility census was 134, which required 4.47 LPN's during evening shift. Review of the nursing time schedules revealed 2.09 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 6, 2025, the facility census was 134, which required 5.36 LPN's during day shift. Review of the nursing time schedules revealed 5.19 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 6, 2025, the facility census was 134, which required 4.47 LPN's during evening shift. Review of the nursing time schedules revealed 3.09 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 6, 2025, the facility census was 134, which required 3.35 LPN's during night shift. Review of the nursing time schedules revealed 2.78 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 7, 2025, the facility census was 138, which required 4.60 LPN's during evening shift. Review of the nursing time schedules revealed 3.13 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 8, 2025, the facility census was 138, which required 4.60 LPN's during evening shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 8, 2025, the facility census was 138, which required 3.45 LPN's during night shift. Review of the nursing time schedules revealed 3.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 9, 2025, the facility census was 136, which required 5.44 LPN's during day shift. Review of the nursing time schedules revealed 5.19 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 9, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 2.97 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 9, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.03 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 10, 2025, the facility census was 137, which required 5.48 LPN's during day shift. Review of the nursing time schedules revealed 4.19 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 10, 2025, the facility census was 137, which required 4.57 LPN's during evening shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 10, 2025, the facility census was 137, which required 3.43 LPN's during night shift. Review of the nursing time schedules revealed 2.03 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 11, 2025, the facility census was 137, which required 5.48 LPN's during day shift. Review of the nursing time schedules revealed 3.38 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 11, 2025, the facility census was 137, which required 4.57 LPN's during evening shift. Review of the nursing time schedules revealed 2.25 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 11, 2025, the facility census was 137, which required 3.43 LPN's during night shift. Review of the nursing time schedules revealed 2.06 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 5.44 LPN's during day shift. Review of the nursing time schedules revealed 4.25 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 2.03 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.06 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 5.44 LPN's during day shift. Review of the nursing time schedules revealed 4.25 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 2.03 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.06 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 13, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 1.97 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 13, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.84 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 14, 2025, the facility census was 138, which required 4.60 LPN's during evening shift. Review of the nursing time schedules revealed 4.16 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 14, 2025, the facility census was 138, which required 3.45 LPN's during night shift. Review of the nursing time schedules revealed 3.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 15, 2025, the facility census was 136, which required 4.53 LPN's during evening shift. Review of the nursing time schedules revealed 2.13 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 15, 2025, the facility census was 136, which required 3.40 LPN's during night shift. Review of the nursing time schedules revealed 2.78 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 16, 2025, the facility census was 137, which required 4.57 LPN's during evening shift. Review of the nursing time schedules revealed 3.00 LPN's provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 16, 2025, the facility census was 136, which required 3.43 LPN's during night shift. Review of the nursing time schedules revealed 2.97 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.






 Plan of Correction - To be completed: 06/09/2025

Director of Nursing/Assistant Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI.
Scheduler and Nursing Leadership were reminded as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility staffing sheets, it was determined that the facility failed to provide a minimum of 3.2 hours of direct resident care for each resident in a 24 period for 14 of 21 sampled days (April 27, 2025, through May 16, 2025).

Findings include:

Review of facility nursing staffing revealed the following days where the staffing hours of direct resident care fell below the required 3.2 hours:

April 27, 2025 - 3.10
April 28, 2025 - 2.91
May 2, 2025 - 2.96
May 3, 2025 - 2.89
May 4, 2025 - 3.06
May 6, 2025 - 3.16
May 8, 2025 - 3.01
May 9, 2025 - 3.08
May 10, 2025 - 2.96
May 11, 2025 - 2.51
May 12, 2025 - 2.81
May 14, 2025 - 3.19
May 15, 2025 - 3.01
May 16, 2025 - 3.13


The above findings were confirmed with facility's administration on May 27, 2025, at 11:00 a.m.






 Plan of Correction - To be completed: 06/09/2025

 Director of Nursing/Assistant Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI.
Scheduler and Nursing Leadership were reminded as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.


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