A list of the most recent deficiencies for Luther Manor Communities. 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 | 2023-11-02 | 2023-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-02 | 2023-11-13 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-26 | 2023-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-25 | 2023-10-10 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-09-25 | 2023-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-25 | 2023-10-10 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-26 | 2023-10-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-26 | 2023-10-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-26 | 2023-10-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-26 | 2023-10-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-26 | 2023-10-03 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-09-26 | 2023-09-29 | 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 | 2023-09-26 | 2023-09-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-26 | 2023-09-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-26 | 2023-09-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-26 | 2023-09-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-07-05 | 2022-08-05 | 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 | 2022-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-05 | 2022-08-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-05 | 2022-08-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-05 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-05 | 2022-08-05 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-05 | 2022-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-05 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-05 | 2022-07-12 | 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 | 2020-02-20 | 2020-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-20 | 2020-03-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-20 | 2020-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-20 | 2020-03-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-26 | 2020-03-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-26 | 2020-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-26 | 2020-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-26 | 2020-02-26 | N |
