Columbia Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and interview, the facility failed to complete and submit a Minimum Data Set (MDS) discharge assessment in a timely manner in two (2) of (2) discharged residents reviewed. Findings include:On 09/11/2025 at 9:58 AM, during a record review and interview with Registered Nurse (RN) #2/ MDS nurse, it was revealed that Resident #98 was admitted on [DATE] and discharged home on [DATE]. The discharge assessment with an Assessment Reference Date (ARD) of 06/14/2025, was submitted on and accepted on 07/09/2025, which is 25 days after the discharge date . On 09/11/2025 at 2:10PM, in an interview with the Administrator, the MDS discrepancy was discussed and the Administrator verbalized understanding of the importance of getting MDS records submitted on time. On 09/11/2025 at 2:24 PM, in an interview with the Director of Nursing (DON), the MDS discrepancy was discussed. The DON stated that she was aware of the discrepancy and saw where it could be a problem.Record review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews and facility policy review the facility failed to follow the comprehensive care plan related to Percutaneous Endoscopic Gastrostomy (peg) tube medication for one (1) of (1) peg tube medication observations. Resident #16Findings Include:A record review of the facility's Care Plans, Comprehensive Person-Centered last review date 1/2023, revealed A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.A record review of Resident #16 comprehensive care plan created on 8/19/25 included interventions Administer (proper name of each medication) as ordered.During an observation on 09/10/25 at 9:00 AM, during morning medication administration by Licensed Practical Nurse (LPN) #2 revealed LPN#2 crushed the medications and placed each medication separately in a dispense cup with 5 cubic centimeters (cc) water. The following medications were given by peg tube Amiodarone HCl Oral Tablet 400 MG…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews and facility policy review the facility failed to administer medications by Percutaneous Endoscopic Gastrostomy (peg) tube according to physician orders for one (1) of four (4) medication observations. Resident #16.Findings Include:A record review of the facility's Administrating Medication through an Enteral Tube last reviewed date of 6/2025 revealed .General Guidelines.3. Administer each medication separately and flush between medications.On 09/10/25 at 9:00 AM, during an observation morning med administration by Licensed Practical Nurse (LPN) #2 revealed LPN#2 crushed the medications and placed each medication separately in a dispense cup with 5 cubic centimeters (cc) water. The following medications were given by peg tube Amiodarone HCl Oral Tablet 400 MG (Amiodarone HCl, Aspirin Oral Tablet Chewable 81 MG (Aspirin) , Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Apixaban Oral Tablet 2.5 MG (Apixaban), Furosemide Oral Tablet 20 MG (Furosemide), lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide daily oral care for over three weeks for a resident who was totally dependent on staff for personal hygiene and oral care. This failure resulted in visible plaque buildup and placed the resident at risk for oral infection, discomfort, and diminished quality of life for one (1) of five (5) residents reviewed for activities of daily living (ADLs). Resident #43. Findings include: A record review of the facility policy Activities of Daily Living (ADL) Supporting revised 3/2018 revealed, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene On 9/8/25 at 1:07 PM, during an observation and interview with Resident #43, he communicated that it had been over three weeks since his teeth had last been brushed. He communicated a desire to have his teeth brushed at least once…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review the facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature for five (5) of (5) sampled food items. Specifically, the facility failed to ensure that meals were maintained at appropriate temperatures prior to service, which had the potential to affect the taste, safety, and nutritional value of meals served to residents.Findings include:A record review of the facility policy titled Food: Quality and Palatability, dated 2/2023, revealed .Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.Definitions.Proper (safe and appetizing) temperature. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction.On 9/8/25 at 11:49 AM, temperatures of food items on the steam table were recorded as follows: chicken breast 109 Fahrenheit (F), pureed noodles 100 F, pureed peas 101 F, and pureed chicken 119 F. Only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews and facility policy review, the facility failed to administer medication in a manner to prevent infection for one (1) of four (4) medication administrations observed. Resident #99. Findings Include:A record review of the facility's Infection Prevention and Control Program with a revision date of 6/30/25 revealed An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection .On 09/10/25 at 8:25 AM, revealed Licensed Practical Nurse (LPN)#1 administered morning medication consisting of: Renvela Oral Tablet 800 milligrams (mg), Aspirin Enteric Coated (EC) Tablet Delayed Release 81 mg, B-Complex/Folic Acid/Vitamin C Oral Tablet Extended Release (B-Complex w/ C & Folic Acid),Clopidogrel Bisulfate Tablet 75 MG, Hydralazine HCl Oral Tablet 100 MG by mouth and Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) one drop in each eye. LPN#1 gathered the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and policy review, the facility failed to ensure placement was checked for a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administration of medications for one (1) of two (2) residents observed with PEG tubes. Resident #6. Findings include: Review of the facility's policy titles, Enteral Feedings Safety Precautions, reviewed January 2023, revealed, Purpose: To ensure the safe administration of enteral nutrition . General Guidelines . Prevention aspiration 1. Check enteral tube placement every 4 hours and prior to feeding or administration of medication . On 5/8/24 at 8:06 AM, in an observation of Resident #6 receiving medications per PEG tube, Licensed Practice Nurse (LPN) #1 did not confirm placement prior to administering Ferrous Sulfate solution 220 milligrams (mg), Clonidine HCL 0.1 mg, Levothyroxine Sodium 175 micrograms (mcg) and Amlodipine Besylate 10 mg. On 5/8/24 at 8:18 AM, in an interview with LPN #1, she confirmed she forgot to check PEG tube placement prior to administering medications through Resident #6's tube.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, facility investigation, and policy review the facility failed to ensure a resident was protected from sexual harassment/sexual abuse for one (1) of four (4) residents sampled. Resident #1 Findings include: A review of the facility's policy, Abuse Prohibition Policy, revised 11/7/2023, revealed, INTENT: .Each resident has the right to be free from abuse, mistreatment . DEFINITIONS: Sexual abuse includes, but is not limited to rape, sexual harassment, sexual coercion or sexual assault . Identification: 1. Any allegations of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately .Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions . Record review of the Facility Investigation with an initiation date of 11/26/23 revealed that on 11/26/23, Certified Nurse Aide (CNA) #2 reported that CNA #1 had made unwanted, inappropriate sexually, explicit suggestions toward her. The facility had initiated an investigation that included reports…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review the facility failed to prevent the possible spread of infection for two (2) of seven (7) residents observed for care. Resident #12 and #26. Findings Include: A review of the facility's policy, Hand washing/Hand Hygiene, with a revised date of 3/1/2020 revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for .l. After contact with blood or bodily fluids, and after contact with objects . m. After removing gloves . Resident #12 On 06/14/22 at 02:54 PM, the State Agency (SA) observed Certified Nursing Assistant (CNA) #2 provide incontinent care for Resident #12. While moving the overbed table, the wash basin and the resident's personal back scratcher fell onto the floor. CNA #2 retrieved the wash basin from the floor and placed it on the resident's bed, and then retrieved the residents personal back scratcher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.