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Deficiency Records for Columbia Lutheran Home
View the most recent health deficiencies and inspection results for Columbia Lutheran Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Columbia Lutheran Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-02-06 | 2026-03-02 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-03-20 | 2025-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-20 | 2025-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-20 | 2025-04-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-03-20 | 2025-04-28 | N |
| 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. | Health | 2025-03-20 | 2025-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-20 | 2025-04-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-03-20 | 2025-04-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-03-20 | 2025-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-20 | 2025-04-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-03-20 | 2025-04-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-03-20 | 2025-04-28 | N |
| 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. | Health | 2025-03-20 | 2025-04-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-03-20 | 2025-04-28 | N |
| Provide large enough exits. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2025-03-20 | 2025-04-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-28 | 2024-04-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-28 | 2024-04-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-28 | 2024-04-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-28 | 2024-04-09 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-28 | 2024-04-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-28 | 2024-04-09 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-28 | 2024-04-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-28 | 2024-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-28 | 2024-04-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-28 | 2024-04-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-02-28 | 2024-04-09 | N |
| Post nurse staffing information every day. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-28 | 2024-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-04-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-28 | 2024-04-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-28 | 2024-04-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-28 | 2024-04-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-28 | 2024-04-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-07 | 2023-12-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-07 | 2023-12-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-07 | 2023-12-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-03 | 2022-12-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-03 | 2022-12-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-03 | 2022-12-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-03 | 2022-12-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-03 | 2022-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-03 | 2022-12-02 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Meet other general requirements. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Develop a communication plan. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-11-03 | 2022-11-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-03 | 2022-11-30 | N |