A list of the most recent deficiencies for Luther Manor. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-01 | 2024-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-01 | 2024-03-04 | Y |
| 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 | 2024-02-01 | 2024-03-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-01 | 2024-03-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-01 | 2024-02-06 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-27 | 2023-12-15 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-07-27 | 2023-09-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-27 | 2023-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-27 | 2023-08-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-27 | 2023-08-25 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-07-27 | 2023-08-25 | Y |
| 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 | 2023-07-27 | 2023-08-25 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-27 | 2023-08-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-27 | 2023-08-23 | 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 | 2023-07-27 | 2023-08-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-27 | 2023-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-27 | 2023-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-05 | 2023-05-05 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-04 | 2022-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-04 | 2022-04-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-29 | 2022-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-29 | 2022-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-29 | 2022-04-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-29 | 2022-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-29 | 2022-04-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-29 | 2022-04-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-29 | 2022-03-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-27 | 2021-06-29 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-05-27 | 2021-06-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-27 | 2021-06-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-05-27 | 2021-06-29 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-10 | 2020-01-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-10 | 2020-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-10 | 2020-01-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-05 | 2020-01-10 | 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 | 2019-12-05 | 2020-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-05 | 2020-01-10 | 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 | 2019-12-05 | 2020-01-10 | N |
