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Deficiency Records for Lutheran Home at Hollidaysburg
A list of the most recent deficiencies for Lutheran Home at Hollidaysburg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lutheran Home at Hollidaysburg. 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? |
|---|---|---|---|---|
| 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 | 2023-10-12 | 2024-01-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-12 | 2024-01-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-12 | 2023-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-28 | 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 | 2023-10-12 | 2023-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-28 | 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 | 2023-10-12 | 2023-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-04 | 2023-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-04 | 2023-11-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-11-21 | 2023-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-21 | 2023-02-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-16 | 2023-01-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-16 | 2023-01-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-16 | 2023-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-16 | 2023-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-16 | 2023-01-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-16 | 2023-01-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-16 | 2023-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-16 | 2023-01-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-16 | 2023-01-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2023-01-07 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-11-21 | 2022-12-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-21 | 2022-12-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-21 | 2022-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-21 | 2022-12-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-21 | 2022-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-08-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-06 | 2022-08-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-04-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-05 | 2022-03-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-05 | 2022-03-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-05 | 2022-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-05 | 2022-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-05 | 2022-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-05 | 2022-03-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-05 | 2022-03-01 | 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 | 2022-01-05 | 2022-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-05 | 2022-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-03-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Meet other general requirements. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-03 | 2021-12-20 | N |
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