A list of the most recent deficiencies for Columbia Crest Center. 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 | 2023-10-18 | 2023-12-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-10-18 | 2023-12-08 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-10-18 | 2023-11-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-18 | 2023-11-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-18 | 2023-11-20 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-18 | 2023-11-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-18 | 2023-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-18 | 2023-11-20 | 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 | 2023-10-18 | 2023-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-18 | 2023-11-20 | 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 | 2023-10-18 | 2023-11-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-18 | 2023-11-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-10-18 | 2023-11-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-11-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-18 | 2023-11-20 | 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 | 2023-10-18 | 2023-11-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Meet other general requirements. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-10-11 | 2023-11-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-31 | 2023-07-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-17 | 2023-05-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-30 | 2023-03-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-10 | 2022-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-19 | 2022-11-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-26 | 2022-09-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-26 | 2022-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-26 | 2022-09-30 | 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 | 2022-08-26 | 2022-09-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-10 | 2021-06-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-03 | 2021-06-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-03 | 2021-06-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-03 | 2021-06-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-17 | 2020-02-24 | 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 | 2020-01-17 | 2020-02-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-17 | 2020-02-24 | 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 | 2020-01-17 | 2020-02-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-17 | 2020-02-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-17 | 2020-02-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-01-17 | 2020-02-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-17 | 2020-02-24 | 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 | 2020-01-17 | 2020-02-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-17 | 2020-02-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-17 | 2020-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-17 | 2020-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-17 | 2020-02-24 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2020-01-17 | 2020-02-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-01-09 | 2020-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-01-10 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2020-01-09 | 2020-01-10 | N |
