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Deficiency Records for Luther Home
A list of the most recent deficiencies for Luther Home. 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 Home. 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 | 2024-08-21 | 2024-09-23 | 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 | 2024-08-21 | 2024-09-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-08-21 | 2024-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-21 | 2024-09-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-20 | 2024-09-23 | 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 | 2024-08-20 | 2024-09-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-20 | 2024-09-23 | 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 | 2024-08-20 | 2024-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-20 | 2024-09-23 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-17 | 2024-02-17 | Y |
| 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 | 2023-09-14 | 2023-10-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-07 | 2023-07-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-07 | 2023-07-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-07 | 2023-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-07 | 2023-07-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-07 | 2023-07-07 | 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 | 2023-06-07 | 2023-07-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-06-07 | 2023-07-07 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-01-06 | 2023-02-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-05 | 2022-08-02 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-07-05 | 2022-08-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-05 | 2022-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-05 | 2022-08-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-05 | 2022-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-05 | 2022-08-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-05 | 2022-08-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-07-05 | 2022-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-05 | 2022-08-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-27 | 2022-08-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-27 | 2022-08-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-27 | 2022-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-27 | 2022-08-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-06-27 | 2022-08-02 | N |
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