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Deficiency Records for Luther Manor Retirement and Nursing Center
A list of the most recent deficiencies for Luther Manor Retirement and Nursing Center. 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 Manor Retirement and Nursing Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-18 | 2023-12-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-18 | 2023-12-01 | 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 | 2023-10-18 | 2023-12-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-18 | 2023-12-01 | 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 | 2023-10-18 | 2023-12-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-18 | 2023-12-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-18 | 2023-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-12-01 | 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 | 2023-10-18 | 2023-12-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-18 | 2023-12-01 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-04-26 | 2023-05-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-19 | 2022-09-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-10 | 2022-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-07 | 2020-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-03-13 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-07 | 2020-03-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-06 | 2019-01-18 | 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 | 2018-12-06 | 2019-01-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-06 | 2019-01-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-06 | 2019-01-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-06 | 2019-01-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-12-06 | 2019-01-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-12-06 | 2019-01-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-06 | 2019-01-18 | 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 | 2018-12-06 | 2019-01-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-06 | 2019-01-18 | N |
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