Deficiency Records for Columbia Lutheran Home
Updated as of October 01, 2020
This is not the most recent data for Columbia Lutheran Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Respond appropriately to all alleged violations. | Health | 2019-04-17 | 2019-05-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-04-17 | 2019-05-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-06 | 2019-04-05 | Y |
| 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2018-06-05 | 2018-06-29 | Y |
| 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 | Y |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2017-12-01 | 2017-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-01 | 2017-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-01 | 2017-12-22 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-05-10 | 2017-05-26 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-01 | 2017-05-26 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-05-01 | 2017-05-26 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-01 | 2017-05-26 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-05-01 | 2017-05-26 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-01 | 2017-05-26 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-01 | 2017-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-01 | 2017-05-26 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-01 | 2017-05-26 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-05-01 | 2017-05-26 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-05-01 | 2017-05-26 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-01 | 2017-05-26 | N |
