Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LUTHER OAKS
BLOOMINGTON, IL · 19 certified beds · Last Life Safety survey August 1, 2024
CMS Certification Number 146184 · first certified October 2017
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
24 citations — more than 73% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2025 to September 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
11 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 22, 2022 | 10 |
| August 2, 2023 | 13 |
| August 1, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | 2 | 2023-08-02 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-08-02 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2023-08-02 |
| E-0029 | Develop a communication plan. | 2 | 2023-08-02 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2023-08-02 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2023-08-02 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2023-08-02 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-01 |
What the citations cover
- Emergency Preparedness Deficiencies 11
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Construction Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 11 |
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 1, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 16, 2024) |
August 2, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 7, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (September 7, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (September 7, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (September 30, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 30, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 18, 2023) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 28, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 5, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Waiver has been granted (December 6, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 5, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 5, 2023) |
June 22, 2022 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 15, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (August 15, 2022) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (August 15, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (August 15, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 15, 2022) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (August 8, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 15, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 15, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 19, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 21, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.