Columbia Lutheran Home

Inspectors wroteBased on interview and record review, the facility failed to notify a resident and their representative of a discharge in writing for 1 of 3 residents (Resident 1), reviewed for discharge process. This failure placed the resident and their representative at risk for not having an opportunity to make an informed decision about the discharge and about their rights to appeal the discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored and handled appropriately in accordance with professional standards of food safety for 2 of 2 kitchen refrigerators (Kitchen Reach-In refrigerator and Kitchen Walk In refrigerator), 1 of 1 kitchen dry storage room, 2 of 7 unit refrigerators ([NAME] dining room pantry white refrigerator and [NAME] pantry silver refrigerator), 1 of 3 dining rooms ([NAME] dining room), and 2 of 4 halls (Dogwood and [NAME]), reviewed for food services. The failure to date and discard food items past the use by/expire date, cover food items during meal tray delivery, and use appropriate food handling when assisting residents placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive system for ensuring residents and representatives could anonymously report their concerns for 2 of 2 facility floors (First Floor & Second Floor), reviewed for grievances. This failure placed residents and representatives at risk for unresolved concerns, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), intellectual disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) forms were accurate and/or sent out timely for a Level II PASARR referral for 5 of 7 residents (Residents 2, 22, 34, 63 & 39), reviewed for PASARRs. This failure placed the resident at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene and proper use of gloves were followed during resident care and housekeeping for 3 of 7 staff (Staff Y, Z & K), failed to ensure hand hygiene and/or sanitation of medication trays during medication administration were performed for 2 of 3 staff (Staff U & V), and failed to ensure Enhanced Barrier Precautions (EBP- additional infection control measures focusing on gown and glove use during high-contact resident care) practices were followed for 1 of 3 staff (Staff W), reviewed for infection control. In addition, the facility failed to ensure proper sanitization of medical equipment were conducted for 2 of 3 staff (Staff W & CC) and failed to properly handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag for 1 of 4 residents (Resident 41). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated, assessed, and obtained a physician order for safe administration of medications for 1 of 2 residents (Resident 285), reviewed for self-medication administration. This failure placed the resident at risk for medication errors, adverse medication interactions, and complications.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 17 residents (Resident 39), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments in capturing appropriate diagnosis placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and develop care plans for 2 of 17 residents (Residents 49 & 1), reviewed for comprehensive care planning. The failure to implement and/or develop care plans for nutrition, nail care and weight monitoring placed the residents at risk for malnutrition, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct timely care plan meetings with residents and/or their representatives for 2 of 3 residents (Residents 2 & 22), reviewed for care planning. This failure placed the residents and/or their representatives at risk for not having input regarding care goals, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff documented medications in accordance with professional standards for 1 of 7 residents (Resident 388), reviewed for medication administration. This failure placed the resident at risk for medication errors and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 2 of 2 residents (Residents 22 & 9), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy and properly store nebulizer (medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask) equipment placed the residents at risk for respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure required qualifications were up to date for 1 of 18 staff (Staff EE), reviewed for qualified dietary staff. This failure placed residents at risk of receiving unsafe dietary services from staff that did not have a current food handler's permit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received weekly menus consistently for 1 of 2 residents (Resident 33) and to provide an ordered nutritional supplement for 1 of 1 resident (Resident 49), reviewed for dining services. This failure placed the residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representative were provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record for 2 of 5 residents (Residents 22 & 63), reviewed for COVID-19 immunizations. This failure placed the residents at risk for COVID-19 infection and denied the residents and/or their representative of the right to make informed decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 58 of 58 days (01/01/2024 to 02/27/2024), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 2 of 4 refrigerators (Kitchen and Dining Room Refrigerators) and 2 of 2 (Kitchen's Freezer and Walk-In Freezer) freezers reviewed for food services. The failure to label and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medication storage rooms (First Floor Medication Storage Room), and 1 of 2 medication carts ([NAME] Medication Cart), reviewed for medication storage and medication administration. These failures placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was maintained related to urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 2 residents (Resident 123), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their representatives of risks and benefits before administering psychotropic (mind altering) medications for 2 of 5 residents (Residents 29 & 55), reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed before making decisions about their medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (healthcare directives) were obtained from the residents and/or their representatives and ensure a copy was readily available in the medical records for 3 of 6 residents (Residents 29, 17 & 47), reviewed for advance directives. This failure placed the residents and/or their representatives at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure missing/lost items had resolutions for 1 of 2 residents (Resident 45), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency for 1 of 2 residents (Resident 37), reviewed for abuse allegations. This failure placed the resident at risk for repeated incidents, potential unidentified mistreatment, and lack of protection due to unrecognized abuse.

Inspectors wroteBased on interview and record review, the facility failed to identify abuse allegation and failed to ensure the abuse allegation was thoroughly investigated for 1 of 2 residents (Resident 37) reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the residents and/or representatives describing the reason for transfers for 2 of 3 residents (Residents 37 & 17), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make an informed decision about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 2 of 3 residents (Residents 37 & 17), reviewed for hospitalization. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for 3 of 6 residents (Residents 51, 58 & 1), reviewed for timeliness in transmitting discharge Minimum Data Set (MDS) assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 1), reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding discharge placed the resident at risk for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 6 residents (Residents 39 & 47), reviewed for baseline care plan. This failure resulted in the residents and/or their representatives not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for 3 of 15 residents (Residents 45, 47 & 29), reviewed for care planning. The failure to develop care plans for antibiotic (medication to treat infection) use, care of diabetes (the body has trouble controlling blood sugar used for energy), and hospice (end of life care), placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise comprehensive care plans for 2 of 15 residents (Resident 16 & 55), reviewed for care plan revision. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff documented in accordance with professional standards for 2 of 4 staff (Staff R & Staff Y), reviewed for medication administration. This failure placed the residents at risk for medication errors and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathing/showers and personal/grooming care were consistently provided for 2 of 2 residents (Residents 1 & 27), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decreased self-esteem, and a diminished qualify of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure use of respiratory equipment were maintained to include care of oxygen tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) in accordance with professional standards of practice for 3 of 3 residents (Residents 46, 37 & 47), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess bed rails (bed enablers) and provide risks/benefits of use to meet the needs of 2 of 3 residents (Residents 46 and 65), reviewed accident hazards. This failed practice placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag appropriately for 1 of 2 residents (Resident 123) and failed to ensure hand hygiene was performed during dining observations for 2 of 2 residents (Residents 66 & 30), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 3 of 5 Residents (Residents 5, 55 & 47) related to pneumococcal vaccinations (vaccines use to prevent pneumonia [lung infection]). This failure placed residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure bed rails (bed enablers) were safe to use for 2 of 3 residents (Residents 65 & 46), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN - a required form that provides an estimated cost of continuing services, which may no longer covered by Medicare [government health insurance program]) for 1 of 4 residents (Resident 1), reviewed for liability notices. This failure placed the resident and/or their representative at risk for not having adequate information to make financial decisions related to continued stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 2), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegation of abuse for 1 of 1 resident (Resident 2), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on observation, interview, record review, the facility failed to have an effective Infection Prevention and Control Program (IPCP) by ensuring acceptable hand hygiene was consistently performed to prevent the potential transmission of infections for 7 of 38 residents (Residents 30, 22, 1, 8, 24, 31 & 59). The facility did not ensure that staff performed hand hygiene during incontinence care and assisting residents in the dining room to prevent cross contamination. These failures placed the residents at risk for facility acquired or healthcare-associated infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure residents were provided with dignified existence and self-determinations for 4 of 38 residents (Residents 12, 30, 8 & 22) reviewed for resident rights. The facility failed to ensure Resident 12 received showers per her preference. Additionally, the facility failed to ensure Residents 30, 22 & 18 were treated in a dignified manner during meal service. These failures placed the residents at risk for a diminished quality of life, self-worth, and overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administration of medication had been adequately assessed to self-administer medication for 1 of 1 resident (Resident 45) reviewed for administration of medications. This failure placed the resident at risk for unsafe medication administration, medication error and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 66) reviewed for limited Range of Motion (ROM) was provided treatment/services to maintain/increase range of motion to bilateral [both] feet/ankles. This failure placed the resident at increased risk for decreased ROM, contractures (limited movement of a joint), and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, and the facility failed to ensure expired medication solution were not stored with un-expired residents' medications/supplies in 1 of 2 medication storage rooms (Second Floor Medication Room). This failure placed the residents at risk for receiving compromised and/or ineffective medication solutions, which potentially result to the residents not receiving the therapeutic effect of the medication solution, and/or possibly experience adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' code status were consistent throughout the electronic medical record (EMR) for 2 of 3 residents (Residents 269 & R270) reviewed for advance directives. This failure placed the residents at risk for incorrect life sustaining treatment and a diminished quality of life.