Inspection Reports for
Luther Oaks

Facility Reported Incident IL#199348: no violations cited.

The establishment was found in compliance with all applicable regulations during this facility reported incident investigation.

FRI IL 194756: Section 295.6000 a)13) cited.

The establishment failed to prevent theft of a resident's wallet and $30. The facility investigated and identified a suspected staff member who no longer works there.

The facility committed to assessing affected residents, inspecting all memory care residents' belongings, updating policies, providing education to staff and responsible parties, and implementing a monitoring process with audits to ensure compliance.

The facility committed to assess affected residents, review all residents' medication and contact records, update policies, provide education to staff, and implement audits to ensure compliance with medication reminders and notification policies.

Complaint #2565185/IL194038: Sections 295.2030 b)5) and 295.5000 b)1)2)3) cited.

The establishment failed to notify a resident's family of a hospital transfer and failed to properly observe and remind residents to take medications as required by their service plans.

FRI IL 192407: The incident can be substantiated. No violations cited.

The establishment was found in compliance with all applicable regulations during the original investigation of FRI IL 192407.

Facility Reported Incident #188798: no violations cited.

The establishment was found in compliance with all applicable regulations during this facility reported incident investigation.

Complaint 2561467 / IL 186891: no violations cited.

For this survey, the establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.

Complaint 2561165 / IL 186258: Complaint cannot be substantiated. No violations cited.

The establishment was found in compliance with all applicable regulations during the complaint investigation.

Complaint 24610448 / IL 183151: Complaint cannot be substantiated. No violations cited.

The establishment was found in compliance with all applicable regulations during the complaint investigation.

The facility committed to conduct audits, in-service nursing staff on shower and meal schedules, and implement documentation and random audits to ensure compliance with resident rights.

Complaint #2469359/IL180976: Section 295.6000 a)5) cited. Complaint #2469481/IL181211: no violation.

The establishment failed to provide meals and showers per resident service plans for three residents. The facility acknowledged issues with shower documentation and has implemented new procedures to improve compliance.

The facility was found to have deficiencies related to falls prevention and medical record documentation for residents at risk of falls.

The facility was found to have multiple deficiencies including failure to protect residents from abuse, incomplete PASARR assessments, inadequate psychotropic medication management, lack of discharge planning, insufficient shaving care, improper respiratory care, lack of qualified dietary staff, failure to honor resident food preferences, unsanitary food storage and preparation, inadequate infection prevention and control program, and absence of an antibiotic stewardship program.

One Type 1 deficiency was cited related to failure to provide a safe transfer for one resident.

The facility failed to notify the physician and resident representative of a change in medical condition for one resident, failed to investigate falls and implement post-fall interventions for three residents, and failed to provide adequate supervision to prevent falls.

The facility failed to administer Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 to four of five residents reviewed for vaccinations. The facility policy requires offering immunizations according to current standards and documentation of education and refusals.

The facility was found to have multiple deficiencies including failure to act on resident grievances, failure to notify family and physicians of changes in condition, failure to implement physician orders, incomplete wound care and nutritional interventions, inadequate fall investigations, and failure to provide ordered therapeutic diets and supplements.

The facility failed to transmit Discharge Minimum Data Set assessments timely for two residents, failed to provide appropriate pressure ulcer care for two residents, and failed to store and label premade salads and gelatin properly, potentially affecting all 18 residents.