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Deficiency Records for Luther Oaks

A list of the most recent deficiencies for Luther Oaks. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Luther Oaks. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-17 2024-02-21 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-01-29 2024-02-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-29 2024-02-21 Y
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-08-16 2023-12-06 N
Establish emergency prep training and testing. Fire Safety 2023-08-16 2023-09-30 N
Establish staff and initial training requirements. Fire Safety 2023-08-16 2023-09-30 N
Conduct testing and exercise requirements. Fire Safety 2023-08-16 2023-09-18 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-08-02 2023-09-11 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-08-16 2023-09-07 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-08-16 2023-09-07 N
Develop a communication plan. Fire Safety 2023-08-16 2023-09-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-16 2023-09-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-08-16 2023-09-05 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-16 2023-09-05 N
Install a two-hour-resistant firewall separation. Fire Safety 2023-08-16 2023-08-31 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-16 2023-08-31 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-08-16 2023-08-28 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-04-24 2023-05-18 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-04-24 2023-05-18 Y
Honor 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. Health 2023-04-24 2023-05-18 Y
Provide care by qualified persons according to each resident's written plan of care. Health 2023-04-24 2023-05-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-04-24 2023-05-18 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-04-24 2023-05-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-04-24 2023-05-18 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-04-24 2023-05-18 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-07-06 2022-08-15 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-07-06 2022-08-15 N
Develop a communication plan. Fire Safety 2022-07-06 2022-08-15 N
Establish emergency prep training and testing. Fire Safety 2022-07-06 2022-08-15 N
Conduct testing and exercise requirements. Fire Safety 2022-07-06 2022-08-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-07-06 2022-08-15 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-07-06 2022-08-15 N
Install a two-hour-resistant firewall separation. Fire Safety 2022-07-06 2022-08-08 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-07-06 2022-07-21 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-07-06 2022-07-19 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-06-22 2022-07-07 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-06-22 2022-07-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-06-22 2022-07-07 N
Address patient/client population and determine types of services needed. Fire Safety 2021-04-23 2021-06-30 N
Address subsistence needs for staff and patients. Fire Safety 2021-04-23 2021-06-30 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2021-04-23 2021-06-30 N
Establish policies and procedures including evacuation. Fire Safety 2021-04-23 2021-06-30 N
Establish policies and procedures for sheltering. Fire Safety 2021-04-23 2021-06-30 N
Establish policies and procedures for medical documentation. Fire Safety 2021-04-23 2021-06-30 N
Establish policies and procedures for volunteers. Fire Safety 2021-04-23 2021-06-30 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-04-23 2021-06-30 N
List the names and contact information of those in the facility. Fire Safety 2021-04-23 2021-06-30 N
Provide emergency officials' contact information. Fire Safety 2021-04-23 2021-06-30 N
Establish methods for sharing information. Fire Safety 2021-04-23 2021-06-30 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-04-23 2021-06-30 N
Provide family notifications of emergency plan. Fire Safety 2021-04-23 2021-06-30 N
Establish staff and initial training requirements. Fire Safety 2021-04-23 2021-06-30 N
Implement emergency and standby power systems. Fire Safety 2021-04-23 2021-06-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-04-23 2021-06-30 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2021-04-23 2021-06-30 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2021-04-23 2021-06-30 N
Provide a written emergency evacuation plan. Fire Safety 2021-04-23 2021-06-30 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-04-23 2021-06-30 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-04-23 2021-06-30 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2021-04-15 2021-05-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-15 2021-05-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-04-15 2021-05-14 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-04-15 2021-05-14 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2021-04-15 2021-05-14 N
Implement 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. Health 2021-04-15 2021-05-14 N
Ensure that residents are free from significant medication errors. Health 2021-04-15 2021-05-14 N
Ensure 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. Health 2021-04-15 2021-05-14 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2021-04-15 2021-05-14 N
Provide and implement an infection prevention and control program. Health 2021-04-15 2021-05-14 N

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