Public Record
Luther Oaks
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 19
- Avg. residents per day
- 17.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 53
- Inspections on file
- 10
- Last inspection
- 2025-11-05
*CMS
*CMS
*CMS
Citations
53 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0758Generalpotential for harm
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.
- 0801Generalpotential for harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0013Generalpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0133Generalpotential for harm
Install a two-hour-resistant firewall separation.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0029Generalpotential for harm
Develop a communication plan.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0585Generalpotential for harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- 0659Generalpotential for harm
Provide care by qualified persons according to each resident's written plan of care.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0640Generalpotential for harm
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0013Generalpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0029Generalpotential for harm
Develop a communication plan.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0133Generalpotential for harm
Install a two-hour-resistant firewall separation.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
Inspection findings
What the surveyors documented
The verbatim CMS Form 2567 statement of deficiencies for each survey, straight from the federal record. Open a report for the full findings and plan of correction.
- Inspection2 deficiencies
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…
Read full statement of deficiencies - Inspection13 deficiencies
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - Inspection2 deficiencies
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify…
Read full statement of deficiencies - Inspection14 deficiencies
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administer Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal…
Read full statement of deficiencies - Inspection8 deficiencies
F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to act upon grievances/concerns received during resident council meetings for…
Read full statement of deficiencies - Inspection13 deficiencies
F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to transmit Discharge Minimum Data Set (MDS) assessments within 14 days…
Read full statement of deficiencies
FAQ
Questions and answers
- What is Luther Oaks?
- Luther Oaks is a Medicare- and Medicaid-certified nursing home in Bloomington, IL, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 146184.
- What is the CMS rating for Luther Oaks?
- Luther Oaks has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Luther Oaks have?
- Luther Oaks is certified for 19 beds. It serves an average of 17.9 residents per day.
- How many citations does Luther Oaks have?
- Luther Oaks has 53 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Luther Oaks last inspected?
- Luther Oaks was last inspected on November 5, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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