Deficiency Records for Columbia Lutheran Home
Updated as of March 01, 2022
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? |
---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-08-16 | Y |
Respond appropriately to all alleged violations. | Health | 2021-02-11 | 2021-03-08 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-12-18 | 2021-01-14 | Y |
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-10-07 | 2020-11-13 | Y |
Respond appropriately to all alleged violations. | Health | 2020-10-07 | 2020-11-13 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-06-26 | 2020-07-24 | N |
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 |
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 |
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 |
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 |