Columbia Crest Center

In the surveyor’s words

From the most serious findings on record at Columbia Crest Center, in the surveyor’s own words.

• Immediate jeopardy, patternF607Nov 19, 2024

  Based on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify, prevent, protect, investigate, and report abuse/neglect allegations for 3 of 3 residents (Residents 2, 38, and 62) who had reported allegations of abuse and neglect by filing out grievance forms. Review of the facility's Grievance/Concern forms, dated 06/01/2024 to 11/14/2024, showed 10 additional allegations of abuse/neglect involving 7 of 7 residents (Residents 226, 228, 227, 2, 54, 11, and 40) reviewed for abuse/neglect. The facility did not have a process to identify allegations of abuse/neglect, that were written as grievances and required thorough and timely investigations. […]

• Actual harm, isolatedF600Nov 19, 2024

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 11 residents (Resident 35) reviewed for neglect. Resident 35 experienced harm when staff failed to provide Resident 35 water when requested, failed to assess skin excoriation (loss of the top layer of the skin and a portion of the middle layer of the skin due to scratching or an injury) to Resident 35's coccyx (tailbone) and perineum (the area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), and administer pain medications as needed at their end of life per Resident 35's advanced directive (a legal document that outlines preferences for medical care in the event you… […]

• Actual harm, isolatedF689Nov 19, 2024

  Based on observation, interview, and record review, the facility failed to provide an environment that was free from avoidable accident hazards for 1 of 5 residents (Resident 4) reviewed for accidents with injury. This failed practice placed the residents at risk for avoidable accidents when Resident 4 experienced actual harm when their fifth toe on their right foot was broken while being pushed in their wheelchair. Additionally, the facility failed to ensure a safe smoking area and storage of smoking paraphernalia (items or equipment associated with a particular activity, hobby, or lifestyle) for 3 of 3 residents (Residents 13, 27, and 45) reviewed for safe smoking. […]

• Actual harm, isolatedF686Mar 18, 2024

  Based on interview and record review, the facility failed to implement pressure offloading interventions timely to prevent the development and/or worsening of pressure injuries for 2 of 3 residents (Residents 1 and 3) reviewed for pressure injuries. Resident 1 experienced harm when they developed a facility acquired pressure injury with infection to their coccyx (tailbone) and placed other residents at risk of new or worsening skin impairments. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016 defines pressure injury stages as follows: Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). […]

• Actual harm, isolatedF686Oct 18, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with standards of practice regarding thorough/accurate assessments, obtaining a medical evaluation, and implementing preventative measures to prevent the development or worsening of pressure injuries for 3 of 6 sampled residents (Residents 42, 45, and 15), reviewed for pressure injuries. This deficient practice resulted in actual harm to Resident 42 when avoidable, facility acquired pressure ulcers developed, and placed other residents at risk for worsening of pressure injuries, medical complications, and unmet care needs. Findings included . […]