Deficiency Records for Luther Manor Retirement and Nursing Center

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Updated as of May 01, 2024

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Deficiency Records for Luther Manor Retirement and Nursing Center

A list of the most recent deficiencies for Luther Manor Retirement and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Luther Manor Retirement and Nursing 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?
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 2023-10-18 2023-12-01 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-10-18 2023-12-01 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 2023-10-18 2023-12-01 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-10-18 2023-12-01 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 2023-10-18 2023-12-01 N
Ensure that residents are free from significant medication errors. Health 2023-10-18 2023-12-01 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-10-18 2023-12-01 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-10-18 2023-12-01 N
Provide and implement an infection prevention and control program. Health 2023-10-18 2023-12-01 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 2023-10-18 2023-12-01 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-10-18 2023-12-01 N
Have an enclosure around a vertical opening shaft. Fire Safety 2023-10-18 2023-12-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-10-18 2023-12-01 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-10-18 2023-12-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-10-18 2023-12-01 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-10-18 2023-12-01 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-10-18 2023-12-01 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-10-18 2023-12-01 N
Have proper medical gas storage and administration areas. Fire Safety 2023-10-18 2023-12-01 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2023-04-26 2023-05-19 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-08-19 2022-09-09 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-06-10 2022-08-03 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2020-02-07 2020-03-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-07 2020-03-13 N
Use approved construction type or materials. Fire Safety 2020-02-07 2020-03-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-02-07 2020-03-13 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-02-07 2020-03-13 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2020-02-07 2020-03-13 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-02-07 2020-03-13 N
Have proper medical gas storage and administration areas. Fire Safety 2020-02-07 2020-03-13 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-12-06 2019-01-18 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 2018-12-06 2019-01-18 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-12-06 2019-01-18 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2018-12-06 2019-01-18 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 2018-12-06 2019-01-18 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2018-12-06 2019-01-18 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2018-12-06 2019-01-18 N
Conduct testing and exercise requirements. Fire Safety 2018-12-06 2019-01-18 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 2018-12-06 2019-01-18 N
Provide properly protected cooking facilities. Fire Safety 2018-12-06 2019-01-18 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-12-06 2019-01-18 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2018-12-06 2019-01-18 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-12-06 2019-01-18 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-12-06 2019-01-18 N
Have proper medical gas storage and administration areas. Fire Safety 2018-12-06 2019-01-18 N

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