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Deficiency Records for St Luke Community Nursing Home
View the most recent health deficiencies and inspection results for St Luke Community Nursing Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St Luke Community Nursing Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-03-27 | 2025-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-27 | 2025-06-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-03-27 | 2025-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-27 | 2025-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-27 | 2025-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-27 | 2025-04-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-03-27 | 2025-04-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-03-27 | 2025-04-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-03-14 | 2024-06-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-14 | 2024-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-14 | 2024-06-01 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-03-14 | 2024-06-01 | 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 | 2024-03-14 | 2024-06-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-14 | 2024-04-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-14 | 2024-04-25 | 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 |
| Implement a program that monitors antibiotic use. | 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 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 |
| 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 | 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 |
| 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 |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-16 | 2023-03-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-16 | 2023-03-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-16 | 2023-03-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-16 | 2023-03-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-16 | 2023-03-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-16 | 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 | 2023-03-16 | 2023-02-16 | N |