Inspection Reports for
The Columns Rehabilitation and Healthcare Center
3025 FOURTH STREET, JONESVILLE, LA, 71343
Back to Facility Profile8 Reports
Inspection Report — Dec 3, 2025
Annual Inspection CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's Quality Assurance and Performance Improvement (QAPI) program, specifically regarding falls.
Findings
The facility failed to develop, implement, and maintain an effective and comprehensive QAPI program for falls. Documentation of the ongoing QAPI program was not provided, potentially affecting 85 residents.
Deficiencies (1)
F0865: The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and maintained for falls. There was no evidence of an effective QAPI program for falls.
Report Facts
Fall incidents: 15
Fall incidents: 20
Fall incidents: 14
Residents affected: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed no evidence of effective QAPI for falls | |
| Director of Nursing | Interviewed and confirmed no evidence of effective QAPI for falls |
Inspection Report — May 14, 2025
Annual Inspection CMS
Date: May 14, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident care (call light accessibility, medication documentation, care plan implementation, ADL assistance, nutrition), medication storage, and food service safety. Several residents did not receive care or services as ordered, and expired or improperly stored supplies were found.
Deficiencies (11)
F 0558: The facility failed to ensure a resident's call light was accessible, compromising prompt assistance for Resident #51.
F 0582: The facility failed to inform residents #45 and #70 of charges for services on Advanced Beneficiary Notices of Non-Coverage.
F 0605: The facility failed to ensure physicians documented clinical rationale for denial of dose reduction of psychotropic medications for Residents #37 and #51.
F 0656: The facility failed to implement the person-centered care plan for Resident #45, specifically monitoring and recording food intake.
F 0657: The facility failed to revise Resident #45's care plan after quarterly assessment to reflect current mobility status.
F 0677: The facility failed to provide necessary grooming and personal hygiene care, including nail care, for Resident #24.
F 0687: The facility failed to provide appropriate foot care and podiatry referral for Resident #24 with diabetes.
F 0692: The facility failed to ensure Resident #69 received ordered nutritional supplements, assistance with eating, and accurate meal intake documentation.
F 0761: The facility failed to ensure nursing carts were free of loose pills and expired supplies, compromising medication safety.
F 0803: The facility failed to follow recipes for puree diets, resulting in inadequate portion sizes for 10 residents.
F 0812: The facility failed to store and serve food in accordance with professional standards, including improper storage of sugar scoop and open fish breading.
Report Facts
Residents sampled: 26
Weight loss: 14.3
Weight loss: 8
Expired supplies: 17
Expired supplies: 8
Expired supplies: 1
Expired supplies: 1
Residents on puree diet: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 DON | Director of Nursing | Acknowledged call light accessibility issue and care plan deficiencies |
| S5 Accounts Manager | Responsible for completing ABN forms, confirmed missing cost information | |
| S6 LPN | Licensed Practical Nurse | Confirmed call light was not accessible to Resident #51 |
| S9 LPN | Licensed Practical Nurse | Oversaw medication cart observation and confirmed loose pills |
| S10 RN | Registered Nurse Clinical Support | Confirmed weight loss reporting procedures and meal intake documentation issues |
| S11 CNA | Certified Nursing Assistant | Documented meal intake for Resident #69, observed missed supplement |
| S12 LPN | Licensed Practical Nurse | Confirmed Resident #69 did not receive nutritional supplement |
| S13 ADON | Assistant Director of Nursing | Signed Pharmaceutical Consultant Reports |
| S14 MD | Physician | Failed to provide clinical rationale for dose reduction denial |
| S15 CNA | Certified Nursing Assistant | Documented meal intake and described meal set up for Resident #69 |
| S17 LPN | Licensed Practical Nurse | Confirmed CNA responsibilities for meal intake documentation |
| S18 Treatment Nurse | Confirmed inability to trim Resident #24's toenails and presence of expired supplies | |
| S19 CQI | Confirmed medication storage policy and observations | |
| S3 Dietary Manager | Dietary Manager | Confirmed recipe deviations and food storage issues |
| S4 | Prepared puree diet not following recipe | |
| S7 CNA | Certified Nursing Assistant | Assisted Resident #69 and described meal set up |
Inspection Report — Apr 9, 2025
Complaint Investigation CMS
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical abuse involving multiple residents at the facility.
Complaint Details
The complaint investigation substantiated resident-to-resident physical abuse involving Residents #2, #3, and #4. Video surveillance and staff interviews confirmed the incidents occurred on 03/04/2025. Resident #3 exhibited escalating behavior leading to physical altercations with Residents #2 and #4.
Findings
The facility failed to ensure that Resident #2, Resident #3, and Resident #4 were free from physical abuse by other residents. Video surveillance and interviews confirmed incidents of physical altercations among these residents on 03/04/2025, with Resident #3 both a victim and perpetrator of abuse.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse by other residents. Specifically, Resident #2 was physically abused by Resident #3; Resident #3 was physically abused by Resident #4; and Resident #4 was physically abused by Resident #3 on 03/04/2025.
Report Facts
Residents affected: 3
Date of incident: Mar 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 DON | Director of Nursing | Interviewed and confirmed abuse incidents and reviewed video surveillance |
| S2 CNA | Certified Nursing Assistant | Reported Resident #3's disruptive behavior and removal from dining room |
| S3 LPN | Licensed Practical Nurse | Reported on Resident #3's behavior and care plan status |
Inspection Report — Nov 13, 2024
CMS
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation and treatment protocols related to a resident's skin tear.
Findings
The facility failed to ensure that the person-centered care plan for treatment of a skin tear was followed for one resident. Specifically, a dressing change ordered every three days was not completed as required, resulting in a blood-stained bandage remaining in place beyond the scheduled change date.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. A resident's skin tear treatment was not performed as ordered, with a dressing change missed on 11/05/2024.
Report Facts
Residents Affected: 1
Inspection Report — Aug 7, 2024
Complaint Investigation CMS
Date: Aug 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident physical abuse incident involving Resident #4 and Resident #5.
Complaint Details
The complaint investigation was substantiated based on video surveillance, clinical records, and staff interviews confirming the resident-to-resident abuse incident on 05/21/2024.
Findings
The facility failed to ensure Resident #4's right to be free from resident-to-resident physical abuse. Video surveillance and interviews confirmed an altercation where Resident #5 kicked Resident #4's walker, threw a plastic bowl hitting Resident #4 causing a laceration, and both residents engaged in hitting each other resulting in injuries.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse by other residents. Resident #4 was physically abused by Resident #5, resulting in a laceration and skin tear during a resident-to-resident altercation.
Report Facts
Residents affected: 5
BIMS score: 8
BIMS score: 11
Incident date: May 21, 2024
Inspection Report — Mar 8, 2024
Routine CMS
Date: Mar 8, 2024
Visit Reason
Routine inspection of The Columns Rehabilitation and Healthcare Center to assess compliance with regulatory standards related to resident care, environment, grievance procedures, care planning, activities of daily living, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and hygiene, failure to maintain a clean environment, failure to follow grievance procedures, failure to develop complete care plans for recurrent UTIs, failure to provide adequate assistance with activities of daily living, and failure to properly store food resulting in expired items being available for resident consumption.
Deficiencies (6)
F 0550: The facility failed to ensure Resident #46 was treated with respect and dignity by not removing her long facial hair approximately half an inch long on chin and lip despite her request.
F 0584: The facility failed to maintain a clean environment by allowing Resident #53's personal recliner to remain dirty with dried brown sticky substances and sand-like material.
F 0585: The facility failed to follow its grievance policy by not completing a grievance for Resident #62 who reported missing underwear that was neither replaced nor formally addressed.
F 0656: The facility failed to implement a person-centered care plan for Resident #25's recurrent urinary tract infections, despite documented episodes and antibiotic treatments.
F 0677: The facility failed to provide necessary grooming and personal hygiene assistance to Residents #10 and #21, who were observed with untrimmed fingernails and facial hair.
F 0812: The facility failed to ensure food safety by storing expired items including sea salt and thickened orange juice containers, some of which were distributed to residents.
Report Facts
Sampled residents: 23
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Expired food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | Provided care for Resident #46 and reported on facial hair removal |
| S5 LPN | Licensed Practical Nurse | Confirmed Resident #46's facial hair condition |
| S18 LPN | Licensed Practical Nurse | Interviewed regarding Resident #53's recliner cleanliness |
| S9 CNA | Certified Nursing Assistant | Interviewed about Resident #53's recliner use and cleaning |
| S10 Housekeeping | Housekeeping Staff | Responsible for cleaning Resident #53's recliner |
| S17 Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about grievance procedure failure for Resident #62 |
| S7 RN/CCN | Registered Nurse/Case Coordinator Nurse | Interviewed about care planning failure for Resident #25 |
| S2 DON | Director of Nursing | Confirmed grooming needs for Resident #10 |
| S4 RN Treatment Nurse | Registered Nurse Treatment Nurse | Confirmed fingernail care needs for Resident #21 |
| S6 Dietary Manager | Dietary Manager | Interviewed about expired food items found in kitchen |
Inspection Report — May 24, 2023
Complaint Investigation CMS
Date: May 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely and appropriate pain management to a resident who required such services.
Complaint Details
The investigation was triggered by complaints that Resident #1 did not receive timely pain medication after a fall on 05/08/2023 resulting in a fracture diagnosed on 05/10/2023. The complaint was substantiated with findings of delayed pain medication administration and inadequate pain assessments.
Findings
The facility failed to ensure Resident #1 received timely pain management after a fall resulting in an acute proximal ulnar fracture. Documentation and administration of pain medication were delayed, and pain assessments were inconsistently performed despite the resident's complaints and visible injury.
Deficiencies (1)
F 0697: The facility failed to provide safe, appropriate pain management for a resident requiring such services. Resident #1 did not receive timely intervention or adequate pain medication following a fall and fracture of the left arm.
Report Facts
Pain medication doses not given: 0
Hydrocodone-Acetaminophen doses first given: 1
Pain levels documented: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 LPN | Licensed Practical Nurse | Reported working the night Resident #1 returned from hospital and did not administer pain medication despite resident's complaints. |
| S6 LPN | Licensed Practical Nurse | Called physician to refill pain medication on 05/11/2023 after resident denied pain but was concerned about future need. |
| S3 RN | Registered Nurse | Reviewed narcotic record and confirmed medication arrival date and administration details. |
| S1 DON | Director of Nursing | Acknowledged resident did not receive pain medication or Tylenol from 05/09/2023 through 05/11/2023 and confirmed resident could communicate pain. |
Inspection Report — Feb 8, 2023
Routine CMS
Date: Feb 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and appropriate care for residents with specific medical needs such as dental/oral health, medication management, nutrition, and urinary catheter care.
Findings
The facility was found deficient in ensuring accurate resident assessments, developing comprehensive and timely care plans addressing medical and nutritional needs, and providing appropriate catheter care to prevent urinary tract infections. Several residents' care plans and assessments did not accurately reflect their conditions or required interventions.
Deficiencies (4)
F 0641: The facility failed to ensure accurate dental/oral assessments for Resident #71, whose assessments did not reflect broken, missing, or loose teeth and dentures despite observed dental issues.
F 0656: The facility failed to develop a comprehensive person-centered care plan for Resident #63 to address antidepressant and anticoagulant medication management as ordered.
F 0657: The facility failed to review and revise Resident #79's care plan to include significant weight loss and related interventions within 7 days of assessment.
F 0690: The facility failed to provide appropriate care for Resident #13 with an indwelling urinary catheter, as the catheter bag was found uncovered, on the floor, and without a securing leg strap as ordered.
Report Facts
Sampled residents: 34
Resident #71 admission date: 06/18/2021 (date, not numeric value)
Resident #63 admission date: 05/22/2020 (date, not numeric value)
Resident #79 weight loss percentage: 16.9
Resident #13 admission date: 09/21/2021 (date, not numeric value)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6 DM | Responsible for dental/oral and swallowing/nutrition assessments; acknowledged incomplete dental assessment for Resident #71 | |
| S3 RN | Responsible for other MDS sections; confirmed dental/oral assessments for Resident #71 were inaccurate | |
| S2 DON | Director of Nursing; confirmed awareness of Resident #71's dental issues and inaccurate assessments; confirmed catheter care deficiencies for Resident #13 | |
| S4 RN | Interviewed regarding Resident #63's care plan deficiencies and Resident #13's catheter care | |
| S5 RN | Responsible for Resident #79's care planning; confirmed lack of care plan updates for weight loss | |
| S4 LPN | Confirmed Resident #13's catheter leg strap was not in place as ordered |
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