A list of the most recent deficiencies for Columbia Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 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 |
| Respond appropriately to all alleged violations. | 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Develop a communication plan. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Meet other general requirements. | Fire Safety | 2022-11-02 | 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 | 2022-11-02 | 2022-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-11-02 | 2022-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-08-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-03 | 2019-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-03 | 2019-11-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-03 | 2019-11-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-03 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-03 | 2019-11-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-03 | 2019-11-01 | N |
| Provide appropriate foot care. | Health | 2019-10-03 | 2019-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | 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 | 2019-10-03 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-03 | 2019-11-01 | 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 | 2019-09-25 | 2019-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-25 | 2019-10-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-06-05 | 2018-06-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-05 | 2018-06-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-05 | 2018-06-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-05 | 2018-06-29 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-05 | 2018-06-29 | 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 | 2018-06-05 | 2018-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-05 | 2018-06-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-05 | 2018-06-29 | N |
| Provide appropriate foot care. | Health | 2018-06-05 | 2018-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-05 | 2018-06-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-06-05 | 2018-06-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-06-05 | 2018-06-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-05 | 2018-06-29 | N |
| 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. | Health | 2018-06-05 | 2018-06-29 | N |
| Provide or obtain dental services for each resident. | Health | 2018-06-05 | 2018-06-29 | 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 | 2018-06-05 | 2018-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-05 | 2018-06-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-06-05 | 2018-06-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-06-05 | 2018-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-15 | 2018-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-15 | 2018-06-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-15 | 2018-06-22 | N |
