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Lutheran Retirement Home

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 174
Continuing Care? No
Resident Council? Yes
Family Council? Yes
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 10/26/2011

Date of last standard health inspection: 10/26/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 0
Average number of Health Deficiencies in NY: 2
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in NY: 0 - 10

Inspection, 01/08/2011

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/08/2011 01/06/2001 2 Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 01/08/2011 01/06/2001 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 01/08/2011 01/06/2001 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/08/2011 01/06/2001 1 Some
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/08/2011 01/06/2001 1 Some

Inspection, 02/06/2010

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 02/06/2010 02/06/2012 2 Some
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/06/2010 02/06/2012 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 02/06/2010 02/06/2012 2 Some
Ensure that residents are safe from serious medication errors. 02/06/2010 02/06/2012 2 Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 02/06/2010 02/06/2012 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care by qualified persons according to each resident's written plan of care. 02/06/2010 02/06/2012 2 Few
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. 02/06/2010 02/06/2012 2 Some
Develop policies and procedures for influenza and pneumococcal immunizations. 02/06/2010 02/06/2012 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Allow residents the right to participate in the planning or revision of care and treatment. 02/06/2010 02/06/2012 2 Few

Inspection, 00/03/2010

Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/03/2010 00/02/2012 3 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 00/03/2010 00/02/2012 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/03/2010 00/02/2012 2 Few
Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. 00/03/2010 00/02/2012 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/03/2010 00/02/2012 2 Few
Allow residents the right to participate in the planning or revision of care and treatment. 00/03/2010 00/02/2012 2 Few

Inspection, 01/09/2007

Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 01/09/2007 00/00/0000 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report

Inspection, 01/03/2007

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/03/2007 01/01/2009 2 Some

Inspection, 01/01/2005

Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 01/01/2005 00/00/0000 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident 01/01/2005 00/00/0000 and a family member of situations (injury/decline/ the resident's doctor

Inspection, 00/08/2002

Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/08/2002 00/02/2003 2 Few

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in NY Golden Living Center, Asheville
RN Staff Only1 N/A N/A 3 out of 5 stars
Total Number of Residents 86 167 171
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 16 hours 51 minutes 1 hour 27 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 16 hours 4 minutes 43 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 16 hours 15 minutes 43 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 17 hours 45 minutes 1 hour 42 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 10/26/2011

Automatic Sprinkler Systems in all required areas Partial
Date of last standard fire safety inspection: 10/26/2011
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in NY: 1
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in NY: 0 - 1

Inspection, 01/08/2011

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Portable fire extinguishers. 01/08/2011 01/06/2001 2 Some
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 01/08/2011 01/06/2001 2 Some
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 01/08/2011 01/06/2001 2 Some
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly sized and located linen or trash receptacles. 01/08/2011 01/06/2001 2 Some
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 01/08/2011 01/06/2001 2 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 01/08/2011 01/06/2001 2 Some
Miscellaneous Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Other fire safety features required by fire safety codes. 01/08/2011 01/06/2001 2 Some
Vertical Openings Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. 01/08/2011 01/06/2001 2 Some

Inspection, 02/06/2010

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 02/06/2010 02/06/2012 2 Some
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exit stairways and towers that are smoke proof. 02/06/2010 02/06/2012 2 Some
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 02/06/2010 02/06/2012 2 Some
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are free from obstructions and can be used at all times. 02/06/2010 02/06/2012 2 Some
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 02/06/2010 02/06/2012 2 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 02/06/2010 02/06/2012 2 Some
Miscellaneous Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Other fire safety features required by fire safety codes. 02/06/2010 02/06/2012 2 Some

Inspection, 00/03/2010

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 00/03/2010 00/02/2012 2 Some
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 00/03/2010 00/02/2012 2 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 00/03/2010 00/02/2012 2 Some
 

715 Falconer Street
Jamestown, NY 14701

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