Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luther Oaks during CMS and state inspections, most recent first.
Two residents who experienced falls did not have complete or accurate documentation in their medical records. In one case, a fall and subsequent intervention were not recorded in the nursing notes or care plan. In another, a fall resulting in serious injury was not documented by the DON, and the care plan contained errors regarding the use of enabler side rails. These actions did not meet the facility's documentation standards.
A resident with Parkinson's disease, severe cognitive impairment, and a high risk for falls was transferred by a CNA without the use of a gait belt, despite facility policy and staff expectations requiring its use. Multiple staff confirmed the need for a gait belt during transfers for this resident, and the device was found unused in the room. This failure resulted in a deficiency related to accident hazard prevention and supervision.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 16 residents. During a survey, deficiencies were noted, including unclean kitchen conditions, improper sanitation, and uncovered ice cream canisters. The Dietary Manager in Training had not started required certification courses.
The facility failed to maintain sanitary conditions in food service, affecting all 16 residents. Staff were observed preparing food without hairnets, and food debris was found on trays and tables. Ice cream containers were uncovered, risking cross-contamination. Sanitation practices were inadequate, with improper sanitizer concentration and incorrect cleaning solutions used, violating facility policy.
The facility lacked a comprehensive infection control program, with infection logging only starting recently. An RN failed to follow proper infection control practices by handling a contaminated pill without gloves and not performing hand hygiene before administering nasal spray to a resident.
A resident with severe cognitive impairment exhibited aggressive behaviors towards other residents, including physical and verbal abuse. Despite staff witnessing these behaviors, there was a failure in timely reporting and intervention, leading to continued risk of abuse. The facility's response was inadequate, as the aggressive resident remained in close proximity to the victims in the following days.
A facility failed to conduct a Level Two PASARR for a resident after a new diagnosis of Schizophrenia was added to their medical record. The facility lacked a specific policy for PASARRs, relying on regulations as guidelines. The resident's initial Level One PASARR in 2019 did not recommend further assessment, but the Director of Nursing admitted that a new PASARR should have been completed following the change in psychiatric diagnosis.
A facility failed to assess and track behaviors before diagnosing a resident with Schizophrenia and administering antipsychotic medication. Despite the facility's policy requiring behavior monitoring for residents on psychotropic medications, there was no documented evidence of behaviors justifying the diagnosis. Observations and interviews indicated the resident, with a history of Parkinson's and Dementia, did not exhibit behaviors consistent with Schizophrenia, and the family was unaware of the diagnosis.
A facility failed to provide an individual discharge plan for a resident discharged to Independent Living. The resident, who was cognitively impaired and required assistance with daily activities, had diagnoses of a urinary tract infection and an infection due to an indwelling urethral catheter. The care plan lacked discharge planning information, and the Social Service Designee was unaware of the discharge due to being on vacation. This was contrary to the facility's policy requiring a post-discharge plan to assist with transition.
The facility did not provide adequate shaving care for two residents who required assistance with activities of daily living. One resident, needing extensive help due to confusion and impaired balance, and another with dementia, were both observed with significant beard growth. Staff acknowledged the difficulty in meeting grooming needs due to heavy care demands.
The facility failed to maintain hygienic respiratory care for two residents, as observed with unbagged, undated nebulizer masks and tubing. One resident's mask was found wet and dusty, while another's had debris inside. The DON confirmed the absence of a policy for respiratory equipment maintenance, although it was expected to be rinsed, labeled, and bagged.
A facility failed to implement non-pharmacological interventions and conduct behavior monitoring before administering Seroquel to a resident with dementia. Despite the facility's policy emphasizing non-pharmacological approaches, there was no documentation of behavior tracking or interventions for the resident, who was diagnosed with schizoaffective disorder. Staff reported no recent behaviors, and a family member noted the resident's decline was due to falls related to Parkinson's and dementia.
A resident with Alzheimer's and GERD, requiring a mechanical soft diet excluding broccoli, was served broccoli, leading to a choking incident. Staff failed to adhere to dietary protocols, as the CNA was unaware of the diet book and the Dietary Aide did not regularly check it for updates, despite recent inservice training.
The facility failed to implement an antibiotic stewardship program for two residents, as required by their policy. Antibiotics were prescribed prophylactically without obtaining cultures or sensitivities, and there was a lack of documentation and communication between the Infection Preventionist and physicians. The IP acknowledged the absence of antibiotic logs and expressed concerns about the prophylactic use of antibiotics without cultures.
Failure to Maintain Accurate and Complete Medical Records for Residents with Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of three residents reviewed for falls. In one instance, a resident experienced an unwitnessed fall while transferring from a wheelchair to a recliner. Although an incident report was completed and a non-skid device was added to the recliner as an intervention, there were no corresponding nursing notes in the resident's electronic medical record documenting the fall or the intervention. The Director of Nursing confirmed the absence of documentation and acknowledged that the intervention was not added to the resident's care plan. In another case, a resident fell from her bed, resulting in a subarachnoid hemorrhage and nasal fractures. The fall investigation was completed and signed by the Director of Nursing, but this documentation was not included in the resident's clinical medical record. The nurse on duty at the time of the fall was on break, and upon returning, only documented what she observed, omitting details of the incident that occurred during her absence. The Director of Nursing, who was present during the fall, did not document the event in the resident's chart, despite being the responsible nurse at the time. Additionally, there were inconsistencies in the documentation of the resident's use of enabler side rails. The care plan erroneously indicated the use of enabler bars for bed mobility, while assessments and therapy notes confirmed that the resident did not use such devices. The Care Plan Coordinator admitted to adding the intervention in error, attributing it to standard practices at another facility. These documentation errors are contrary to the facility's own policies, which require accurate and timely documentation of resident status, incidents, and interventions.
Failure to Use Gait Belt During Transfer for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with a progressive neurological condition, Parkinson's disease, muscle weakness, gait abnormalities, and severe cognitive impairment. The resident was identified as high risk for falls and required partial to moderate assistance with transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs and facility policy, a Certified Nurse Assistant (CNA) assisted the resident in transferring from a recliner to a wheelchair without using a gait belt. The CNA acknowledged not using the gait belt and stated that its use depended on the resident's anxiety level, even though the expectation was to always use it for this resident. Multiple staff, including a Registered Nurse, Physical Therapist, and the Director of Nursing, confirmed that all staff are expected to use a gait belt when transferring or walking with this resident. During observation, the gait belt was found unused and rolled up on the counter in the resident's room. The facility's Falls Prevention and Post-Falls Management Policy requires staff to identify fall risks and implement resident-centered prevention plans, which includes the use of assistive devices like gait belts. The failure to use the gait belt as required led to a deficiency in providing adequate supervision and accident hazard prevention.
Failure to Employ Qualified Director of Food and Nutrition
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 16 residents residing in the facility. During the survey conducted from July 30, 2024, to August 1, 2024, several deficiencies were observed in the food and nutrition services. The facility did not maintain cleanliness in the kitchen, with debris present in preparation and storage areas. Additionally, the facility did not sanitize food preparation areas according to its sanitation policy and failed to properly cover and contain ice cream canisters in the freezer. Kitchen staff also did not contain their hair while in the kitchen and food preparation areas. On July 30, 2024, the Dietary Manager in Training stated that she had enrolled in Certified Dietary Manager courses in April 2024 but had not yet started the modules. The facility administrator confirmed that the Dietary Manager in Training had not begun the Certified Dietary Manager training.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, which could potentially affect all 16 residents. Observations revealed that kitchen staff were preparing food without wearing hairnets, and one dietary aide was unsure of their location. Additionally, food crumbs and debris were found on a food tray and soup table, and two large ice cream containers in the freezer were uncovered, posing a risk of cross-contamination. Further inspection showed that the sanitation practices were inadequate. The dietary manager tested the sanitation solution and found it insufficient, with a pH level of 3.0 instead of the required 5.5, indicating a lack of proper sanitizer concentration. Another staff member cleaned the food prep area with a degreaser instead of the appropriate sanitation solution, as she was unaware of its location. These actions were not in compliance with the facility's policy, which mandates the use of approved cleaning solutions and proper sanitation procedures.
Inadequate Infection Control Program and Medication Administration Practices
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the absence of a complete infection control log and inadequate surveillance of infections. The Infection Preventionist (IP) admitted that logging and surveillance of infections only began in July 2024, and prior to that, there was no record-keeping of resident or employee illnesses, nor adherence to McGreer's protocol for antibiotic use. This lack of structured surveillance and documentation has the potential to affect all 16 residents in the facility. Additionally, there was a specific incident involving a registered nurse (RN) who failed to adhere to proper infection control practices while administering medications to a resident. The RN picked up a contaminated pill from a dining room table with bare hands and returned it to the resident, who then ingested it. Furthermore, the RN administered nasal spray to the resident without wearing gloves and did not perform hand hygiene between handling the contaminated medication and administering the nasal spray. The Director of Nurses confirmed that the RN should have used appropriate hand hygiene, as outlined in the facility's handwashing policy.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident, affecting three residents in the sample. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse, including physical harm and intimidation. However, the report details incidents where a resident, identified as R4, who is severely cognitively impaired, exhibited aggressive behaviors towards other residents, including R16 and R271. R4 was noted to have been verbally aggressive and physically abusive, including squeezing R16's hand and pulling her hair, as well as attempting to trip R271 and throwing objects at her. The incidents occurred over two consecutive days, with staff witnessing R4's escalating behaviors. Despite these observations, there was a failure in communication and reporting among the staff. The Social Service Director (SSD) and the Director of Nurses (DON) were not informed of R4's aggressive behavior on the first day, which included throwing a fork and ketchup bottle at R271. This lack of timely reporting prevented appropriate interventions from being implemented to prevent further incidents. The facility's response to the incidents was inadequate, as R4 continued to be in close proximity to R16 in the days following the incidents, despite the previous aggressive interactions. The staff's failure to report and address R4's behavior in a timely manner contributed to the ongoing risk of abuse, highlighting a deficiency in the facility's ability to protect residents from harm.
Failure to Complete Level Two PASARR After New Diagnosis
Penalty
Summary
The facility failed to complete a Level Two Pre-Admission Screening and Resident Review (PASARR) for a resident after a new mental health diagnosis was added to their electronic medical record. This deficiency was identified during an interview and record review, where it was found that the facility did not have a specific policy for PASARRs and instead followed regulations as guidelines. The resident in question had a Level One PASARR completed in 2019, which did not recommend a Level Two assessment. However, a diagnosis of Schizophrenia was added to the resident's medical record in May 2023, and no subsequent PASARR was conducted. The Director of Nursing acknowledged that a PASARR should be completed whenever there is a change in psychiatric diagnosis, indicating that the facility failed to adhere to this requirement.
Failure to Assess Behaviors Before Diagnosing Schizophrenia
Penalty
Summary
The facility failed to properly assess and track behaviors before diagnosing a resident with Schizophrenia and administering antipsychotic medications. The facility's policy on psychotropic medication management emphasizes the use of person-centered, non-pharmacological approaches and requires behavior monitoring for residents on psychotropic medications. However, the facility did not adhere to this policy for one resident, who was diagnosed with Schizophrenia without documented evidence of behaviors warranting such a diagnosis. Observations and interviews with staff and family members revealed that the resident did not exhibit behaviors or hallucinations consistent with Schizophrenia, and the family was unaware of the diagnosis. The resident, who had a history of Parkinson's and Dementia, was initially prescribed Seroquel for delusional disorder while on hospice care in 2022. After being discharged from hospice in January 2023, the resident was diagnosed with Schizoaffective Disorder in May 2023 due to crying, anger, falling, and exit-seeking behaviors. However, these behaviors were also consistent with the resident's existing Dementia diagnosis, and there were no documented behaviors since 2022. The facility's failure to document and assess the resident's behaviors before diagnosing Schizophrenia and administering antipsychotic medication constitutes a deficiency in meeting professional standards of quality care.
Failure to Provide Individual Discharge Plan for Resident
Penalty
Summary
The facility failed to provide an individual discharge plan for a resident, identified as R18, who was discharged to Independent Living. R18 had diagnoses of a urinary tract infection and an infection and inflammatory reaction due to an indwelling urethral catheter. The resident was cognitively impaired and required assistance with activities of daily living, as documented in the Minimum Data Set (MDS) assessment. Despite these needs, R18's care plan did not include any information regarding discharge planning. The Social Service Designee, identified as V19, stated that they were unaware of the discharge due to being on vacation and confirmed that no discharge planning was conducted for R18 in the care plan. The facility's policy on discharge planning and summary, dated April 2024, requires a post-discharge plan and summary to assist residents with their transition, which was not adhered to in this case.
Failure to Provide Shaving Care for Residents
Penalty
Summary
The facility failed to provide adequate shaving care for two residents who were dependent on staff assistance for activities of daily living. Resident 12, who requires extensive assistance due to confusion, disease processes, and impaired balance, was observed with beard hair approximately one half inch in length. Similarly, Resident 13, who requires assistance due to dementia, was also observed with beard growth of the same length. The facility's General Nursing and Personal Care Policy mandates proper daily personal attention, including grooming and personal hygiene for residents unable to perform these tasks independently. Despite this policy, staff members indicated that it was challenging to meet the grooming needs of all residents due to the heavy care demands in the facility.
Deficiency in Hygienic Respiratory Care Practices
Penalty
Summary
The facility failed to provide hygienic respiratory care for two residents, leading to deficiencies in the maintenance and care of nebulizer masks and tubing. For one resident, physician orders required the use of Albuterol Sulfate via nebulizer for respiratory issues such as wheezing and shortness of breath. However, the resident's nebulizer mask was observed on the bedside table, unbagged, undated, and appeared wet and dusty over two consecutive days. The Director of Nursing acknowledged the absence of a policy for respiratory equipment maintenance, although it was expected that such equipment should be rinsed, labeled, and bagged. Another resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had a physician order for Albuterol Sulfate nebulization as needed. The resident's nebulizer tubing and mask were found undated and unbagged on the bedside dresser, with visible debris inside the mask. These observations indicate a lack of proper hygiene and labeling practices for respiratory equipment, contributing to the deficiency.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions and conduct behavior monitoring before administering psychotropic medication to a resident. The facility's policy on psychotropic medication management emphasizes the use of person-centered, non-pharmacological approaches to care. However, for one resident, identified as R6, there was no documentation of behavior tracking or non-pharmacological interventions prior to the administration of Seroquel, an antipsychotic medication. The resident's care plan did not document targeted behaviors or non-pharmacological interventions, which is a deviation from the facility's policy. R6's medical history includes a diagnosis of dementia and a previous diagnosis of delusional disorder while on hospice care. The resident was later diagnosed with schizoaffective disorder due to behaviors such as crying, anger, falling, and exit-seeking, which are also common in dementia. Despite these diagnoses, staff members, including a CNA and an RN, reported not observing any recent behaviors in R6. Additionally, a family member stated that R6 had no history of mental health issues and had declined following falls related to Parkinson's and dementia. The lack of documented behaviors and non-pharmacological interventions prior to the use of psychotropic medication constitutes a deficiency in the facility's care practices.
Failure to Honor Resident's Dietary Preferences Leads to Choking Incident
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to a choking incident. The resident, who has Alzheimer's Disease, Failure to Thrive, and Gastroesophageal Reflux Disease (GERD), was documented to require a mechanical soft textured diet with specific exclusions, including broccoli. Despite this, the resident was served broccoli during a meal, which resulted in a choking episode. The Hospice Certified Nurse Aide assisting the resident was unable to cut the broccoli properly, and the resident began coughing and spitting up pieces of broccoli, indicating a failure to adhere to the prescribed dietary restrictions. The deficiency was further compounded by a lack of communication and adherence to dietary protocols among the staff. The Hospice CNA was unaware of the diet book that contained the resident's dietary restrictions, and the Dietary Aide admitted to not regularly checking the diet book for updates. Although the staff had been inserviced on serving accurate diets, the Dietician confirmed that the dietary staff did not consistently follow the protocol of checking the diet book before serving meals. This oversight led to the resident receiving food that was not in accordance with their dietary needs.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for two of the six residents reviewed for antibiotic use. The facility's Antimicrobial Stewardship Policy, dated 7/31/24, outlines the importance of measuring and improving antibiotic prescriptions and usage to treat infections effectively and combat antibiotic resistance. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and monitoring of antibiotic use for residents R9 and R12. R9 was prescribed Sulfa/Trimethoprim for a wound infection and Methenamine prophylactically for urinary symptoms without obtaining cultures. Similarly, R12 was on Nitrofurantoin prophylactically for urinary symptoms without culture and sensitivity tests. The Infection Preventionist (IP) acknowledged the absence of antibiotic logs, including types of infections, antibiotic usage, cultures, and sensitivities, prior to July 2024. The IP expressed concerns about the prophylactic use of antibiotics without cultures but noted that the prescribing doctors did not agree with her stance. The lack of documentation and communication between the IP and the physicians regarding antibiotic stewardship was evident, as no records of McGreer's criteria or communication with prescribers were found during the survey.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bloomington Rehabilitation & Hcc | 1.5 mi | — | 0 | 0 |
| Westminster Village | 3 mi | ★★★★★ | 4 | 0 |
| Goldwater Care Bloomington | 3.3 mi | ★★★★★ | 4 | 0 |
| Arcadia Care Bloomington | 3.3 mi | ★★★★★ | 13 | 1 |
| Loft Rehab & Nursing Of Normal | 4.5 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.