A list of the most recent deficiencies for St Luke Community Nursing Home. 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? |
|---|---|---|---|---|
| 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 | 2023-03-16 | 2023-04-21 | 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 | 2023-03-16 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-04-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-04-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-16 | 2023-04-21 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-03-16 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-21 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-03-16 | 2023-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-03-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-06 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-06 | 2023-03-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-06 | 2023-03-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-06 | 2023-03-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-06 | 2023-03-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-06 | 2023-03-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-06 | 2023-03-02 | 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 | 2023-02-06 | 2023-02-16 | 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 | 2022-02-16 | 2022-03-25 | 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 | 2022-02-16 | 2022-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-16 | 2022-03-25 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2022-02-16 | 2022-03-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-16 | 2022-03-25 | 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 | 2022-01-20 | 2022-02-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-20 | 2022-02-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-20 | 2022-02-24 | Y |
| 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 | 2020-03-05 | 2020-04-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-27 | 2020-04-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-27 | 2020-04-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-27 | 2020-04-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-27 | 2020-04-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-27 | 2020-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-27 | 2020-04-03 | N |
