The Vardell Report.Luther Manor

Across 11 inspections from July 2023 to July 2026, state surveyors documented 52 findings at Luther Manor; 52 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections

11

2023–2026, complaint and standard

Findings

52

Deficiencies cited by state inspectors

Corrected

52

Of 52 findings, with a recorded correction date

Penalties

5

3 fines; payment not published, 2 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 292026

   Complaint investigation

   2 findings

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Sep 3, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 3, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jan 142026

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Feb 16, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Dec 162025

   Standard health inspection

   5 findings

   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jan 17, 2026
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Jan 17, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Jan 17, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jan 17, 2026
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 17, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jul 292025

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 21, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. May 132025

   Complaint investigation

   1 finding

   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected May 31, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Mar 262025

   Complaint investigation

   1 finding

   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 27, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Oct 312024

   Complaint investigation

   9 findings

   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 25, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 20, 2024
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Nov 25, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Nov 20, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 20, 2024
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Dec 3, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 3, 2024
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Nov 29, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Sep 102024

   Standard health inspection

   14 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Nov 8, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level JImmediate jeopardyCorrected Sep 20, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 8, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 30, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Sep 15, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected Sep 20, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 19, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 20, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 20, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 20, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Sep 19, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Sep 15, 2024

   Enforcement Action

   Civil money penalty, $103,705 imposed September 10, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 10, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed September 10, 2024. Status: Closed, December 3, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 10, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Jun 112024

   Complaint investigation

   5 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Jul 3, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jul 3, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 3, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 3, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 3, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Feb 12024

    Complaint investigation

    6 findings

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Mar 14, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Mar 14, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Mar 4, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 6, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 4, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 4, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Jul 272023

    Standard health inspection

    7 findings

    • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected Aug 25, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Aug 23, 2023
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Aug 23, 2023
    • F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Aug 25, 2023

    Enforcement Action

    Civil money penalty, $25,454 imposed February 1, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed February 1, 2024. Status: Closed, March 14, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 27, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $34,468 imposed June 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 27, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Reporting Suspected Abuse, Cited in Six Inspections

   Inspectors cited F609 in July 2023, February 2024, June 2024, September 2024, October 2024 and July 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F609 across all 11 inspections, oldest to newest
2. 2

   Investigating Alleged Violations, Cited in Six Inspections

   Inspectors cited F610 in July 2023, February 2024, June 2024, September 2024, October 2024 and July 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F610 across all 11 inspections, oldest to newest
3. 3

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in February 2024, June 2024, September 2024 and January 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F686 across all 11 inspections, oldest to newest
4. 4

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in February 2024, June 2024 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F684 across all 11 inspections, oldest to newest
5. 5

   Grievances, Cited in Two Inspections

   Inspectors cited F585 in May 2025 and December 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F585 across all 11 inspections, oldest to newest
6. 6

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in July 2023 and September 2024. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F623 across all 11 inspections, oldest to newest
7. 7

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in September 2024 and October 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F657 across all 11 inspections, oldest to newest
8. 8

   Accident Hazards and Supervision, Cited in Two Inspections

   Inspectors cited F689 in June 2024 and December 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F689 across all 11 inspections, oldest to newest
9. 9

   Pharmacy Services, Cited in Two Inspections

   Inspectors cited F755 in February 2024 and September 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242424252525252626F755 across all 11 inspections, oldest to newest
10. 10

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in July 2023 and September 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242424252525252626F758 across all 11 inspections, oldest to newest
11. 11

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in September 2024 and March 2025. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324242424252525252626F760 across all 11 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in six inspections, most seriously at level D.

2. 02

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in six inspections, most seriously at level D.

3. 03

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level J.

4. 04

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level G.

5. 05

   How do we file a grievance, who answers it, and how quickly?

   Grievances: cited in two inspections, most seriously at level D.

6. 06

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.

7. 07

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

8. 08

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in two inspections, most seriously at level G.

9. 09

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level E.

10. 10

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

11. 11

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in two inspections, most seriously at level D.

12. 12

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

13. 13

    What led to the 2024 fine, and has it been paid?

    A $103,705 civil money penalty was imposed September 10, 2024. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jul 27, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Feb 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jun 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Sep 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Oct 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Mar 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection May 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jul 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Dec 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jan 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Wisconsin state survey agency

  Inspection Jul 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 525588

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.