Deficiency Records for Luther Oaks
Updated as of May 01, 2022
This is not the most recent data for Luther Oaks. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-11 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-07-11 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-11 | 2019-08-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-11 | 2019-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-11 | 2019-08-16 | N |
| Post nurse staffing information every day. | Health | 2019-07-11 | 2019-08-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-11 | 2019-08-16 | 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 | 2019-07-11 | 2019-08-16 | 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 | 2019-07-11 | 2019-08-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-11 | 2019-08-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-11 | 2019-08-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-07-16 | 2019-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-16 | 2019-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-16 | 2019-07-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-16 | 2019-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-16 | 2019-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-06-20 | 2018-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-18 | 2018-07-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-06-18 | 2018-07-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-06-18 | 2018-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-18 | 2018-07-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-06-18 | 2018-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-18 | 2018-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-18 | 2018-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-06-18 | 2018-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-20 | 2018-07-09 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2018-06-20 | 2018-07-08 | 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 | 2018-06-20 | 2018-07-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-20 | 2018-07-06 | 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 | 2018-06-20 | 2018-07-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-20 | 2018-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-20 | 2018-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-20 | 2018-07-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-20 | 2018-07-06 | 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 | 2018-06-20 | 2018-07-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-06-20 | 2018-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-20 | 2018-07-06 | 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 | 2018-06-20 | 2018-07-06 | N |
