Columbia Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records; the physicians orders were not entered into the EMAR (Electronic Medication Administration Record), insulin on the EMAR ordered was withheld by nursing staff, the physician was not notified for withholding medications for 1 of 3 residents reviewed for pharmaceutical services. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and labeled appropriately in 1 of 1 kitchen tours. Food packages were not dated with an open date and use by date, and expired food was not disposed of. (Kitchen)

Inspectors wroteBased on interview, and record review, the facility failed to follow Physicians Orders. A resident with a pressure ulcer did not receive antibiotics and treatment as ordered for 1 of 4 residents reviewed for quality of care. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dependent on staff for ADLs (activities of daily living) were showered for 7 of 8 residents reviewed for ADL care. (Resident B, Resident C, Resident D, Resident E, Resident F, Resident H, and Resident J)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan interventions were implemented for 1 of 1 residents reviewed for falls. Resident G was not observed to have Dycem in use in the wheelchair.(Resident G)

Inspectors wroteBased on record review and interview, the facility failed to ensure a Resident's medication side effects were addressed after a medication change for 1 of 1 residents reviewed for mood and behaviors. (Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary environment during 2 of 2 days of the survey. Resident room halls had a build up of dust/dirt on 2 of 3 units observed, linen closets were not clean, 2 of 2 shower rooms were unclean or not maintained, urinals were not stored properly in a shared restroom, and urine odors were present throughout the survey. (First floor unit, Second floor unit, Hall 1100, 1200, 1400, 1500, 2100, 2200, 2400, 2500, room [ROOM NUMBER], 1208, 12010, room [ROOM NUMBER], 2100 Shower room, 2500 shower room, Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was complete and accurate for 4 of 8 resident records reviewed. Insulin administration and nebulizer treatments were not marked as complete on the Medication Administration Record. (Resident C, Resident O, Resident M, Resident U)

Inspectors wroteBased on interview and record review, the facility failed to follow the nebulizer policy for 1 of 1 resident reviewed for hospital discharge. (Resident D) The resident was not assessed prior to the nebulizer treatment, facility staff did not stay at bedside during the nebulizer treatment; Resident D was later found by a staff member with no respirations or pulse.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective services to treat elevated blood glucose levels were provided in accordance with the physician and Nurse Practitioner (NP) orders for 1 of 2 residents reviewed for insulin administration. (Resident 59) This deficient practice resulted in the resident requiring emergent transport to an acute care hospital intensive care unit for the treatment of diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body doesn't have enough insulin to use blood sugar for energy.)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly dated, labeled, and not expired in 5 of 5 medication carts and 2 of 2 treatment carts. (1500 Hall Medication Cart, 1400 Hall Medication Cart, Memory Care Medication Cart, 2300/2400 Hall Medication Cart, 2500 Hall Medication Cart, First Floor Treatment Cart, Second Floor Treatment Cart)

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of blood glucose levels outside of parameters for 1 of 2 residents reviewed for insulin administration. (Resident 59)

Inspectors wroteBased on record review and interview the facility failed to ensure a resident had a care plan implemented related to frequent urinary tract infections (UTI) with multidrug resistant organisms for 1 of 1 residents reviewed for UTI. (Resident 85)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident did not develop an avoidable pressure ulcer by monitoring skin for 1 of 3 residents reviewed for facility acquired pressure ulcers. (Resident 89)

Inspectors wroteBased on interview, observation, and record review, the facility failed to administer non-pharmalogical or pharmalogical interventions for pain prior to performing wound care for 1 of 2 residents observed for wound care. (Resident 104)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to manufacture and professional standard for 1 of 5 residents observed during medication pass. (Resident 89) Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a 7.69% error rate. (Resident 89)

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was complete and accurate for 1 of 2 residents reviewed for insulin use. (Resident 59)

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were in place for 2 of 2 residents during incontinence care and 1 of 1 resident during wound care. Staff failed to sanitize hands and change gloves between soiled to clean tasks, as well as failed to use enhanced barrier precautions during wound care. (Resident 64, Resident 85, and Resident 86)

Inspectors wroteBased on interview and record review, the facility failed to ensure a the facility implemented the resident's discharge process for 1 of 3 residents reviewed for transfer/discharge rights. A resident who lacked the ability to care for herself discharged home from the facility prior to the arrangement of a home health service and without documentation being completed according to the facility's discharge policy. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure dignity for 3 of 3 residents reviewed for quality of care and treatment. Residents were not assisted with care in a timely manner, not treated with respect and dignity. (Resident B, Resident C, Resident D)

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of medications not available or given as ordered. A resident's non availability of ordered medications was not reported to the physician. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to provide ADL's (activities of daily living), care to 1 of 3 resident's reviewed for bathing. Bathing was not provided to a resident. ( Resident D)

Inspectors wroteBased on observation and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the function of preparing pureed diets for 8 resident meals during 1 of 1 food processing reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide food and drink that are palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test trays and resident interviewed for palatable food served at a palatable temperature.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a nourishing snack at bed time for 5 of 5 residents interviewed for bedtime snacks, and to provide meals at times comparable to normal mealtimes in the community for 1 of 1 meals observed.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 1 of 1 locked dementia unit. (The Cottage)

Inspectors wroteBased on observation and interview the facility failed to accommodate each resident with the use of call lights to summon help from staff for 4 of 4 residents reviewed for assistance. (Resident 26, Resident 117, Resident 29, Resident 114)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal and oral hygiene for 3 of 4 residents reviewed. ( Resident 26, Resident 72, Resident 88)

Inspectors wroteBased on interview, record review, and observation, the facility failed to provide adequate supervision, assistance devices, or interventions to reduce the risk of fall for 2 of 3 residents reviewed for falls with major injuries. (Resident 94 and Resident 39)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment to prevent urinary tract infections (UTIs) for 1 of 1 residents reviewed for catheter use and history of UTIs. A catheter bag was observed on the floor. (Resident 49)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a urostomy care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 residents with a urostomy. (Resident 72)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care (Resident 26).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free of a medication error greater than 5 percent for 1 of 4 residents observed during medication pass. Three medication errors were observed during 35 opportunities for error in medication administration. This resulted in an 8.57% error rate. (Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper storage of medications in 4 of 6 medication/treatment carts. Loose pills and unlabeled biologicals/medications were found in drawers of treatment cart and medication carts. (1400 Hall medication cart, First floor treatment cart, 2200 Hall medication cart, 2400 Hall medication cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate total number of staff and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 6 of 6 days during the annual survey period.