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 Acres Manor during CMS and state inspections, most recent first.
A resident who required assistance with incontinence care activated a call bell and waited over an hour without receiving the needed help. A dietary staff member checked on the resident, learned that incontinence care was needed, and stated they would notify a nurse aide, but no staff responded during the period observed by the surveyor. The DON later acknowledged that a 15-minute wait for call bell response was considered too long, yet the resident’s call bell remained unanswered for a significantly longer period.
A resident who was dependent on staff for toileting and required a Hoyer lift, as documented on the MDS, did not receive timely incontinence care after activating the call bell. The resident reported requesting assistance, and a staff member acknowledged the call bell and stated they would notify a nurse aide, but no one arrived to provide care during an observation period lasting over an hour. This delay occurred despite facility policy requiring support for ADLs and the DON’s acknowledgement that a 15-minute wait for call bell response was considered too long.
Multiple residents and family members reported extended delays in receiving assistance with ADLs, especially during overnight and weekend shifts. Observations included staff not responding promptly to call bells, residents left in soiled conditions, and staff being inattentive or dismissive. The facility administrator confirmed the failure to provide necessary care, resulting in unmet resident needs.
Two residents did not receive prescribed wound care as ordered, including missed or undocumented dressing changes and lack of provider assessment or physician orders for wound treatment. The Nursing Home Administrator confirmed these failures in wound care services.
A resident with severe cognitive impairment was improperly restrained with a gait belt by a nurse aide after a fall, contrary to the facility's restraint-free policy. The restraint was applied without a physician's order or consent and was discovered by the recreation manager, who instructed its removal. The facility confirmed that restraints are not used, and the nurse aide's actions were inappropriate.
Failure to Respond Timely to Resident Call Bell for Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s call bell was answered in a timely manner, as required for reasonable accommodation of resident needs and preferences. During an interview, the resident reported concerns about the length of time it took staff to respond to the call bell, stating that assistance was needed with incontinence care and that the call bell had been activated at approximately 11:00 a.m. At 11:17 a.m., a staff member identified by the resident as dietary staff knocked on the door to inquire about the call bell and, upon being informed that incontinence care was needed, stated that he or she would inform the nurse aide. When the surveyor left the resident’s room at 11:35 a.m., no staff had arrived to provide the requested incontinence care. Subsequent observations from the unit’s nurses’ station until 12:03 p.m. showed no staff responding to the resident’s call bell. In an interview with the DON and NHA, the DON stated that a 15-minute wait time for call bell responses was considered too long. The surveyor then informed the DON that the resident had been waiting for over an hour for assistance after activating the call bell.
Plan Of Correction
R1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide education will be completed regarding call bell response expectations. DON/Designee will complete random facility wide call bell response time audits daily x30 days then 3 times per week for 4 weeks. DON/Designee will report findings to QA Committee for review/recommendation.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically incontinence care, to a resident who was dependent on staff for these needs. Facility policy on ADL support, revised in April 2025, states that residents who are unable to carry out ADLs independently are to receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The resident’s Quarterly MDS dated March 4, 2026, documented that the resident required a Hoyer lift and was dependent on staff for showering/bathing and toileting. On the survey date, the resident reported during an interview at 11:12 a.m. that they required assistance with incontinence care and had activated their call bell at approximately 11:00 a.m. At 11:17 a.m., a staff member entered the room, acknowledged the call bell, and, upon being informed that the resident needed incontinence care, stated they would inform the nurse aide. By 11:35 a.m., when the interview concluded, no staff had come to provide the requested care. Continued observation from the nurses’ station between 11:35 a.m. and 12:03 p.m. showed that no staff responded to the resident’s call for incontinence assistance during that period. When questioned, the DON stated that a 15-minute wait time for call bell responses was considered too long, while the resident had been waiting for over an hour.
Plan Of Correction
Resident 1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide audit of all residents who are dependent for toileting will be completed. Nursing staff will be educated on ASL policy. DON/Designee will complete ADL care audits daily x30 days then three times per week for 4 weeks to ensure proper ADL care is being provided. DON/Designee will report findings to QA Committee for review and recommendations.
Failure to Provide Timely ADL Assistance and Call Bell Response
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for ten of eighteen residents, as evidenced by multiple resident and family complaints, observations, and interviews. Several residents reported extended wait times for assistance, particularly during third shift and when agency staff were present. One resident stated it takes a long time to get back into bed, and another noted insufficient staffing in the evenings. Facility grievances documented instances where residents' call lights were not answered in a timely manner, with one resident waiting over 1.5 hours for care and another having to use the bathroom unassisted due to lack of staff response. Family members also reported concerns about slow call bell response times, especially overnight and on weekends, and described situations where residents were left in soiled conditions or had to wait for extended periods to receive help with toileting. Observations included staff walking past active call bells and sitting at the nurses' station without responding to residents' needs. Family members described finding their loved ones in unsanitary conditions and noted that staff sometimes appeared disengaged or dismissive when concerns were raised. The Nursing Home Administrator confirmed the facility's failure to provide necessary ADL assistance to the affected residents. The cited deficiencies are in violation of 28 PA. Code:201.18(b)(2) Management and 28 PA. Code:201.29(a) Resident's Rights.
Failure to Provide Prescribed Wound Care Treatment and Services
Penalty
Summary
The facility failed to provide prescribed wound care treatment and services for two residents as required by physician orders and facility policy. For one resident with diagnoses of heart failure and diabetes, a physician's order directed daily cleansing and dressing changes for a right lower extremity skin tear. However, observation revealed that the dressing was not changed as ordered, with the dressing dated two days prior, despite documentation indicating the treatment was completed. For another resident with peripheral vascular disease and a history of stroke, an open area on the left shin was identified and treated by an LPN, but there was no evidence in the clinical record that the wound was assessed by a provider or that a physician's order for wound treatment was obtained. Additionally, the dressing on this resident's wound was undated. The Nursing Home Administrator confirmed that prescribed treatment and services related to wounds were not provided for these two residents.
Improper Use of Physical Restraint on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's and severe dementia. The resident was admitted to the facility without any orders for restraints. However, on a specific day, the resident experienced a fall while attempting to stand from a wheelchair. In response, a nurse aide used a gait belt to secure the resident to the wheelchair, effectively restraining them without a physician's order or consent from the resident or their legal representative. The facility's policy states that restraints should only be used as a last resort and with proper authorization, which was not followed in this case. The recreation manager discovered the restraint and instructed the nurse aide to remove it. The nurse aide acknowledged the mistake and removed the gait belt after approximately 30 minutes. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the facility does not use restraints and that the nurse aide's actions were inappropriate.
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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 Lititz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kadima Rehabilitation & Nursing At Lititz | 0.8 mi | ★★★★★ | 4 | 0 |
| Moravian Manor | 1.1 mi | ★★★★★ | 5 | 0 |
| Landis Homes | 2.9 mi | ★★★★★ | 1 | 0 |
| Brethren Village | 3.2 mi | ★★★★★ | 3 | 0 |
| Rehabilitation Center At Brethren Village Llc | 3.2 mi | ★★★★★ | 0 | 0 |
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