Inspection visit
Fire Safety inspection
Citations
24 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
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.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0030GeneralS&S Epotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Epotential for harm
Provide emergency officials' contact information.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0100GeneralS&S Epotential for harm
Meet other general requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0281GeneralS&S Dpotential for harm
Install proper backup exit lighting.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0741GeneralS&S Epotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919GeneralS&S Fpotential for harm
Meet requirements for the use of electrical equipment.
- 0921GeneralS&S Epotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0926GeneralS&S Epotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
FAQ · About this visit
Common questions about this visit
What happened during the October 2, 2025 survey of LUTHER MANOR RETIREMENT & NURSING CENTER?
This was a inspection survey of LUTHER MANOR RETIREMENT & NURSING CENTER on October 2, 2025. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHER MANOR RETIREMENT & NURSING CENTER on October 2, 2025?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address subsistence needs for staff and patients."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.