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Deficiency Records for Columbia Lutheran Home
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.
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? |
|---|---|---|---|---|
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | 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 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 |
| 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 | 2024-02-26 | 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 | 2024-02-26 | 2024-04-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-26 | 2024-04-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-26 | 2024-04-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-26 | 2024-04-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-26 | 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 |
| 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 |
| 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 |
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