A list of the most recent deficiencies for Luther Haven. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-07 | 2024-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-07 | 2024-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-11-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-11-20 | 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 | 2023-09-20 | 2023-11-20 | 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 | 2023-09-20 | 2023-11-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-20 | 2023-11-20 | 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 | 2023-09-20 | 2023-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-11-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-20 | 2023-11-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-20 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-11-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-20 | 2023-11-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-20 | 2023-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-04 | 2023-04-17 | Y |
| 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 | 2022-07-21 | 2022-08-24 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-21 | 2022-08-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-21 | 2022-08-24 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-07-21 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-08-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-21 | 2022-08-24 | 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 | 2022-07-19 | 2022-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-19 | 2022-08-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-07-21 | 2022-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-19 | 2022-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-08-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-07-19 | 2022-08-09 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-09 | 2022-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-25 | 2021-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-25 | 2021-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-25 | 2021-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-05-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-03-25 | 2021-05-10 | 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 | 2021-03-23 | 2021-05-04 | N |
