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? |
|---|---|---|---|---|
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-27 | 2021-08-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-27 | 2021-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-27 | 2021-08-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-27 | 2021-08-17 | Y |
| 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 |
