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Deficiency Records for St Luke's Nursing and Rehabilitation
A list of the most recent deficiencies for St Luke's Nursing and Rehabilitation. 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 St Luke's Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-17 | 2023-08-30 | N |
| Notify 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. | Health | 2023-07-17 | 2023-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-17 | 2023-08-30 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-17 | 2023-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-17 | 2023-08-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-17 | 2023-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-17 | 2023-08-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-07-17 | 2023-08-30 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-17 | 2023-08-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-17 | 2023-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-17 | 2023-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-17 | 2023-08-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-11 | 2020-04-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-11 | 2020-04-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-02-11 | 2020-04-03 | N |
| Provide 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. | Health | 2020-02-11 | 2020-04-03 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2020-02-11 | 2020-04-03 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-11 | 2020-04-03 | 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 | 2020-02-11 | 2020-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-04-03 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-02-25 | 2019-04-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-25 | 2019-04-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-25 | 2019-04-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-25 | 2019-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-25 | 2019-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-25 | 2019-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-25 | 2019-04-01 | N |
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