A list of the most recent deficiencies for St Luke Living 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-05 | 2024-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-22 | 2022-09-23 | N |
| 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 | 2022-06-21 | 2022-07-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-21 | 2022-07-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-21 | 2022-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-21 | 2022-07-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-12-02 | 2021-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-12-02 | 2021-01-29 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Develop a communication plan. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-12-02 | 2021-01-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-10-14 | 2020-11-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-14 | 2020-11-19 | N |
| Respond appropriately to all alleged violations. | Health | 2020-10-14 | 2020-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-14 | 2020-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-14 | 2020-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-14 | 2020-11-19 | 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 | 2020-10-14 | 2020-11-19 | 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 | 2020-10-14 | 2020-11-19 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2020-10-14 | 2020-11-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | Not Fixed | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-22 | Not Fixed | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-22 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | Not Fixed | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-22 | Not Fixed | N |
| Post nurse staffing information every day. | Health | 2024-02-22 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | Not Fixed | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-22 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | Not Fixed | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-22 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-22 | Not Fixed | N |
