Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luther Manor Retirement & Nursing Center during CMS and state inspections, most recent first.
Two residents experienced significant injuries due to the facility's failure to prevent accidents and provide adequate supervision. One resident, dependent on staff for transfers, was injured during a manual transfer when staff could not use a mechanical lift due to a malfunctioning bed, resulting in a severe leg laceration likely caused by contact with a wheelchair pedal. Another resident with dementia and a history of wandering was able to exit the building unsupervised, as the door alarm was not heard by staff, leading to a fall outside and multiple abrasions. In both cases, staff did not follow established safety protocols or ensure effective monitoring.
The facility did not ensure that nurse aides received the required 12 hours of annual in-service education, as there was no documentation or tracking system in place. The DON acknowledged the lack of records and was unaware of the specific educational content required, despite being aware of the 12-hour mandate.
The facility did not maintain an up-to-date facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. Only the first page of the assessment, containing contact and licensing information, was updated, while the rest of the document was outdated. The administrator confirmed the assessment had not been fully updated since his arrival, with updates made only after the survey began.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident with hemiplegia and limited mobility experienced a fall and complained of hip pain, receiving Tylenol twice for pain management. Despite these complaints and administration of pain medication, staff did not notify the physician of the pain until two days later, resulting in a delayed diagnosis of a hip fracture. Facility protocols required timely physician notification of abnormal findings, but this was not followed.
A resident with a prior humerus fracture was found to have a new fracture requiring surgery, but staff did not recognize it as a new injury and failed to report it to the state agency as required. The LPN notified the DON and ADON, but due to uncertainty about the origin of the injury and lack of detailed information, the incident was not reported according to facility policy.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate oversight and prevent injury for two residents, resulting in significant harm. One resident, who had diagnoses including dementia, muscle weakness, reduced mobility, and was dependent on staff for all transfers, was injured during a transfer when staff manually moved the resident due to a malfunctioning electronic bed. The mechanical lift could not be used because the bed would not raise, and staff proceeded with a two-person manual transfer. During this process, the resident sustained a large open laceration to the left lower extremity, which required emergency medical care, including sutures, antibiotics, pain management, and wound care. Documentation and staff statements indicated that the injury likely occurred when the resident's leg caught on the wheelchair pedal, which had not been removed prior to the transfer, contrary to safe transfer practices outlined in the care plan. Another resident, with a history of dementia, Alzheimer's disease, and wandering, experienced an elopement that resulted in a fall with injury. The resident was known to require a wander guard and supervision due to increased confusion and wandering behavior. On the day of the incident, the resident was able to exit the building and was found outside by a pharmacy delivery driver, who later discovered the resident had fallen in the parking lot. Staff interviews and written statements revealed that the door alarm, which was intended to alert staff to unauthorized exits, was either not heard by staff or was not loud enough to be effective throughout the building. Multiple staff members reported not hearing the alarm, and the resident was able to leave the building unsupervised, resulting in abrasions and complaints of pain that required hospital evaluation. In both cases, the facility did not ensure that safety measures and supervision were effectively implemented according to the residents' care plans and needs. The lack of proper use of equipment, failure to follow transfer protocols, and insufficient monitoring of exit alarms directly contributed to the residents' injuries. The report documents that these deficiencies were identified through observation, interview, and record review, and that the facility did not have adequate policies or practices in place to prevent such incidents at the time they occurred.
Failure to Ensure Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service education annually. During the survey, it was found that the facility could not provide a policy regarding the required in-service training for Nursing Assistants when requested. Review of the facility assessment indicated a comprehensive list of staff competencies and annual training requirements, including abuse prevention, dementia care, infection control, and other critical areas. However, there was no evidence that these requirements were being tracked or met for the nurse aides. In an interview, the DON stated that both she and the nurse educator provide in-services and education for CNAs, and that the nurse educator offers education during CNA classes. Despite this, the DON admitted there was no documentation of in-services, nor was there a system in place to track whether CNAs completed the required 12 hours of annual education. The DON was aware of the 12-hour requirement but was not familiar with the specific educational content needed within those hours and had not reviewed the facility assessment to identify the necessary in-service education topics.
Failure to Update Facility-Wide Assessment for Resource Needs
Penalty
Summary
The facility failed to update and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility census was 55 at the time of review. The only updated portion of the facility assessment as of 10/01/25 was the first page, which contained contact and licensing information, while the remainder of the assessment available for review was from 05/01/23 and contained outdated resident information. During an interview, the administrator acknowledged that the facility assessment had not been updated since his tenure began, citing other priorities, and confirmed that only the first page was updated after the annual survey had started.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Notify Physician of Resident's Pain After Fall
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner regarding the resident's complaints of hip pain following a fall. After the resident, who had a history of hemiplegia, muscle weakness, and limited range of motion, slid out of a shower chair and landed on the floor, staff documented the incident and noted initial complaints of right hip soreness. However, the physician was only notified that the resident had fallen, with no mention of the hip pain. The resident continued to complain of pain and received Tylenol twice on the day of the fall, but there was no documentation that the physician was informed of these ongoing complaints or the administration of pain medication. Multiple staff interviews confirmed that the resident's complaints of pain were not communicated to the physician at the time of the fall or when pain medication was administered. The resident's pain persisted, and it was not until two days later that the physician was notified of the pain, at which point an x-ray was ordered. The x-ray, performed three days after the fall, revealed a mildly displaced left femoral neck fracture. Facility protocols required nurses to notify physicians of any abnormal findings or complaints, ensuring thorough assessments and communication. Both the nurse practitioner and the Director of Nursing stated that they expected staff to notify the physician of any complaints of pain following a fall. The failure to communicate the resident's pain complaints and the need for pain medication to the physician resulted in a delay in diagnosis and treatment of the hip fracture.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency for one resident who suffered a new fractured humeral shaft. The resident was admitted to the facility with a prior left humerus fracture and had not experienced any falls or trauma since admission, according to staff documentation and interviews. On a follow-up appointment, it was discovered that the resident had a new fracture requiring surgery, but staff believed it was related to the initial injury and did not recognize it as a new event. The LPN reported the finding to the DON and ADON, but the incident was not reported to the state agency as required by the facility's abuse prevention policy. Interviews with the DON, ADON, and Administrator revealed a lack of clarity regarding whether the fracture was new and whether it constituted an injury of unknown origin. The DON did not consider the fracture reportable due to insufficient information and the absence of witnessed incidents, while the Administrator was unaware it was a new fracture until the state agency's investigation. The facility's policy required immediate reporting of injuries of unknown source, but this was not followed in this case.
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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 Hannibal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Lawn Nursing Home | 1.9 mi | — | 22 | 0 |
| Beloved Health And Rehabilitation Center | 6.8 mi | — | 0 | 0 |
| Beth Haven Nursing Home | 7.8 mi | — | 0 | 0 |
| Sunset Home | 12.9 mi | — | 4 | 2 |
| Good Samaritan Home | 13 mi | — | 1 | 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 August 2026) and official state health department websites.