Inspection Reports for
Columbia Healthcare Center

The facility failed to follow physician's orders for one resident with a pressure ulcer, resulting in missed antibiotic administration and incomplete wound treatments as ordered. Documentation in medication administration records and treatment records was incomplete or missing.

The facility failed to ensure that residents dependent on staff for ADLs were showered as scheduled or per their preferences, with multiple residents not receiving showers or complete bed baths on numerous scheduled days in August 2025. Observations and record reviews revealed inconsistent bathing care, despite care plans and shower schedules indicating otherwise.

The visit was complaint-related, connected to Intake 2592689, involving concerns about care plan implementation, ADL assistance, and behavioral health medication management.

The facility failed to ensure a resident's care plan interventions for fall prevention were implemented, seven residents did not receive showers as scheduled according to their care plans, and one resident's medication side effects were not properly addressed following a medication change.

The facility failed to maintain a safe and sanitary environment, with dust and dirt buildup in multiple hallways, unclean linen closets, improperly stored urinals, unclean shower rooms, and pervasive urine odors throughout the facility.

The investigation covered seven complaints (IN00452997, IN00453214, IN00453166, IN00453005, IN00453237, IN00452975, IN00453317). No deficiencies related to the allegations in these complaints were cited.

No deficiencies were found related to the specific complaints investigated; however, an unrelated deficiency was cited regarding the facility's failure to maintain a safe, sanitary, and comfortable environment, including dust and dirt buildup, unclean linen closets and shower rooms, improper storage of urinals, and persistent urine odors throughout the facility.

This citation relates to complaint IN00449174.

The facility failed to follow nebulizer treatment policies for one resident, resulting in a critical incident where the resident was found without respirations or pulse during treatment. Additionally, documentation for insulin administration and nebulizer treatments was incomplete or missing for multiple residents.

Complaint IN00449174 was substantiated with federal/state deficiencies cited at F695 (respiratory/tracheostomy care and suctioning) and F842 (resident records - identifiable information).

The facility failed to follow nebulizer treatment policy for one resident, resulting in a resident found without respirations or pulse during treatment. Additionally, the facility failed to ensure complete and accurate documentation for insulin administration and nebulizer treatments for multiple residents.

The visit was complaint-related due to allegations of failure to notify physicians of abnormal blood glucose levels, inadequate care planning, medication errors, infection control breaches, and documentation issues. Substantiation status is not explicitly stated.

The facility failed to notify physicians timely of critical blood glucose levels, did not implement appropriate care plans for residents with recurrent UTIs, failed to provide effective treatment for elevated blood glucose resulting in hospitalization, did not monitor skin properly to prevent pressure ulcers, failed to administer pain management appropriately, had medication administration errors including failure to prime insulin pens, had unlabeled and expired medications in medication carts, and failed to maintain complete and accurate medical records. Infection control practices were also inadequate, including failure to use enhanced barrier precautions and proper hand hygiene.

This visit included the investigation of complaints IN00440519, IN00440582, IN00441713, and IN00445070. No deficiencies related to the allegations were cited for these complaints.

The facility was found deficient in multiple areas including failure to notify physicians of abnormal blood glucose levels, incomplete care plans for residents with frequent UTIs, inadequate treatment of elevated blood glucose resulting in hospitalization, failure to monitor skin under immobilizers leading to pressure ulcers, inadequate pain management prior to wound care, medication administration errors including failure to prime insulin pens, improper medication storage and labeling, incomplete documentation of insulin use, and lapses in infection prevention and control practices.

This citation relates to Complaint IN00432722. The complaint involved failure to properly discharge Resident B, who left the facility AMA without proper documentation or education, and the facility did not notify Adult Protective Services despite concerns for the resident's safety.

The facility failed to ensure the resident's discharge process was properly implemented, as Resident B was discharged home without arranged home health services and without completing required discharge documentation. The resident left against medical advice without proper education or AMA observation documentation, and the facility did not contact Adult Protective Services despite concerns.

Complaint IN00432722 was substantiated with deficiencies cited related to discharge planning. Complaints IN00433145 and IN00434200 had no deficiencies related to the allegations.

The facility failed to ensure the proper implementation of the discharge planning process for one resident (Resident B) who was discharged home without arrangements for home health services and without proper documentation according to facility policy. Resident B left the facility against medical advice without appropriate education or documentation, and the facility did not contact Adult Protective Services despite concerns about the resident's safety.

This citation relates to Complaint IN00429431. Complaints included residents waiting over two hours for care, call lights not being answered timely, disrespectful staff behavior, and failure to provide requested items such as ice packs and pillows. Department head reviews and actions included written warnings and staff education.

The facility failed to ensure dignity and timely care for residents, with documented instances of residents waiting over two hours for assistance, staff turning off call lights without providing care, and residents being spoken to disrespectfully. Several grievances were reviewed, confirming these issues, and staff education was completed to address call light response times.

Complaint IN00429431 was substantiated with federal/state deficiencies cited at F550 related to resident rights and dignity. The complaint included reports of residents waiting hours for care, call lights being turned off without care, and disrespectful staff behavior.

The facility failed to ensure dignity and timely care for 3 of 3 residents reviewed. Residents were not assisted promptly, call lights were ignored or turned off without providing care, and residents were treated without respect.

This citation relates to Complaint IN00422524, IN00420692, IN00422380. The complaints involved failure to notify physicians about medication availability and failure to provide bathing care to residents.

The facility failed to notify the physician when ordered medications were unavailable or not administered to Resident B, and failed to provide bathing assistance to Resident D as required. Documentation issues and lack of specific policies for notifying physicians and bathing care were noted.

The investigation was triggered by complaints IN00420692, IN00422524, and IN00422380. Deficiencies related to these complaints were substantiated with citations at F580 (Notification of Changes) and F677 (ADL Care Provided for Dependent Residents).

The facility failed to notify the physician of unavailable or not administered medications for Resident B and failed to provide bathing care to Resident D. Deficiencies were cited related to notification of changes and ADL care for dependent residents.

The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code. Deficiencies included lint accumulation in laundry dryer enclosure, fire rating tags obscured by paint on stairway doors, missing self-closing devices on hazardous area doors, cooktop not deactivated when not in use, fire alarm system trouble light, incomplete sprinkler coverage, sprinkler heads covered with foreign substances, combustible decorations without fire retardant treatment, and missing annual inspection documentation for stairway and laundry chute fire door assemblies.

The facility was found deficient in multiple areas including reasonable accommodations for residents, ADL care for dependent residents, fall prevention, catheter care, urostomy care, respiratory care, medication administration, medication storage, dietary support and food safety, meal/snack provision, and environmental conditions on the dementia unit.

The facility was found deficient in multiple areas including failure to accommodate residents' needs for call lights, inadequate assistance with activities of daily living, insufficient supervision to prevent falls, improper catheter care, unsafe medication storage, poor food service quality and timing, and failure to maintain a safe and clean environment in the dementia unit.

Complaint IN00393930 was substantiated with federal/state deficiencies cited at F550. Complaints IN00391496 and IN00378261 were unsubstantiated due to lack of evidence.

The facility was found to have failed to ensure dignity for one resident (Resident B) by not taking him to the restroom and telling him to soil his brief, including taking his call light away. Complaint IN00393930 was substantiated with related federal/state deficiencies cited at F550. Two other complaints were unsubstantiated due to lack of evidence.