Columbus Health and Rehab

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 39 of 39 residents residing in the facility on 3 of 3 units. R12, R18, R7, R30, R39, R2, R42, and R17 voiced concerns to staff related to receiving hot foods at a cold and undesirable temperature. These residents reside on 3 of 3 units. Surveyor conducted a test tray, and the result was not palatable. R10, R23. R49 and R1 voiced concerns regarding cold food. Evidenced by: The facility did not provide a policy and procedure for food temperatures. Example 1 On 05/19/26 at 12:26 PM during initial screening, R10 stated the food is terrible. Everything is cold. I eat in my room and by the time I get it, it is cold. I occasionally go to the dining room, but it is still cold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 39 residents who reside in the facility. Surveyor observed 3 sprinklers and the surrounding ceiling to be covered in a layer of dust. The sprinklers are directly above food preparation area. Surveyor observed the facility's freezer to have frozen drips hanging from the ceiling and boxes that have ice buildup on and inside with food no longer sealed by the manufacturer. Surveyor observed [NAME] D serving food 2 days without donning a beard net. Surveyor observed 3 dented cans in circulation. Evidenced by:Example 1Facility policy, titled Sanitation, revised 10/22, includes: [...]

Inspectors wroteBased on interview and record review the facility did not ensure prompt resolution of all grievances for 3 of 3 sampled residents (R2, R7, R17) and 2 of 2 supplemental residents (R42, R30) reviewed for grievances. R2, R7, R42, R30, and R17 voiced concerns/grievances to staff. Staff did not follow the facility's grievance process. CNA P (Certified Nursing Assistant), CNA O, and CNA G indicated R2, R7, R42, and R30 voiced concerns related to being served hot food at a cool and undesirable temperature and they did not use the facility's grievance process to track, address, or look for trends throughout the facility. AD S (Activity Director) indicated R7 tells her almost daily that her hot foods are served cold and at an undesirable temperature. Evidenced by: Facility policy, titled Filing Grievances/Complaints, revised 11/2017, includes: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 8 errors out of 29 opportunities that affected 3 out of 4 residents (R41, R21 & R33) included in the medication pass task, which resulted in an error rate of 27.59%.Staff administered R41's lisinopril and hydralazine at 9:15AM. R1's order is to administer at 8:00AM. Staff administered these medications late. Staff administered R21's acetaminophen and senna at 8:58AM. The order is to administer acetaminophen and senna at 7:30AM. Staff administered R21's gabapentin at 8:58AM. The order is to administer gabapentin at 7:00AM. Staff administered these medications late. Staff administered R33's carbidopa-levodopa and dabigatran etexilate at 9:22AM, metoprolol at 9:33AM, and oxybutynin at 9:23AM. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 staff reviewed for background checks. CK D (cook) was hired by the facility on 3/18/26. CK D's Background Information Disclosure (BID) Form, dated 3/18/26, indicated he lived in Iowa and [NAME] Virginia in the last three years. The facility did not do a background check for Iowa or [NAME] Virginia. Evidenced by:The facility policy entitled, F606, F607 Abuse Prevention Program, Screening of Employees, dated 10/25, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 14 Residents (R17) reviewed for abuse. R17 reported an allegation of neglect and the facility did not submit a report to the State Agency (SA). Evidenced by:The facility's F609, Reporting of Abuse Allegation policy, dated 10/25, states, in part: All suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Definitions: [...]

Inspectors wroteBased on interview and record review, the facility did not investigate an alleged violation of neglect for 1 of 14 residents (R17) reviewed for abuse. R17 reported to CNA G that R17 hadn't been changed/cared for all night. The facility did not complete an investigation. Evidenced by:The facility's F607 Abuse Prevention Program, Investigation F600, F602, F603, F610, dated 10/25, states, in part: Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.1. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. R17 admitted to the facility on [DATE] and has diagnoses that include: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R24) reviewed for elopement. The facility did not accurately assess R24's risk for elopement, did not update R24's care plan with personalized interventions when Interdisciplinary team came up with interventions to prevent elopements, and did not follow care planned interventions of increased supervision. R24 was found to be outside ambulating independently. Evidenced by:The facility did not provide a policy related to Elopement. R24 admitted to the facility on [DATE] with diagnoses including dementia. R24's Hospital Discharge Note, dated 10/24/25, includes: . Reason for admission and hospital course: The patient . who comes to . hospital with increasing confusion. She had been wandering outside of her house. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 2 residents reviewed for pressure injuries (R30). R30 was at risk for developing pressure injuries related to immobility and multiple fractures. The facility failed to implement aggressive pressure injury interventions; failed to complete weekly assessments per standard of practice; failed to provide risk and benefits despite knowledge of R30 refusing repositioning. Facility did not assess or measure R30's left gluteal pressure injury. R30 developed two stage three, and one unstageable facility acquired pressure injuries.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the ability to affect all 38 residents. Food items were observed to be spoiled. Scoops were found in containers of sugar. Nutritional supplements were found without use by dates. Four Sysco Imperial Strawberry Shakes were found in the medication room refrigerator with no use by date.

Inspectors wroteBased on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 38 residents residing in the facility. The Facility Assessment did not indicate: [...]

Inspectors wroteBased on observation, interview and, record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census (38). The facility is not monitoring the temperature of 3 of their 5 water heaters as part of their control measures for Water Management Program. The facility's policy and procedure for Pneumococcal Vaccine is not up to date. A breach in infection control was observed with R236, R16, R7, and R22. This is evidenced by: Example 1 Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 13 (R8) residents reviewed for physician notification. R8 experienced an episode of coughing so much phlegm it caused him to have emesis (vomiting) in October 2024. Additionally, R8 had a 4-pound weight increase in one day in February 2025, which is a significant change in relation to R8's medical conditions, which can indicate worsening respiratory symptoms. The facility did not call the on-call physician to allow for alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled, Guidelines for Notifying Physicians of Clinical Problems, dated 10/2024, states, in part: . The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. [...]

Inspectors wroteBased on interview and record review the facility did not ensure services meet professional standards of quality for 1 of 1 residents (R237) reviewed for wound vac therapy (a device that provides negative pressure wound therapy to promote healing). R237 was admitted to the facility with a wound vac, the facility failed to ensure there were physician orders for the provisions of care for the wound vac in the medical record. The facility policy titled, Guidelines for Notifying Physicians of Clinical Problems, dated 10/2024, states, in part: . The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The Charge Nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and management . Immediate Notification (Acute) Problems: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who are continent of bladder and bowel, on admission, receive services and assistance to maintain continence, unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 1 resident's (R25) reviewed for bowel and bladder. The facility did not develop a toileting plan for R25 after they assessed and concluded that R25 would be a candidate for retraining. This is evidenced by: The facility's policy and procedure entitled Urinary Incontinence - Clinical Protocol/Guidelines, with an effective date of 10/2024, states, in part: Assessment and Recognition 1. As part of the initial assessment, the nursing staff will attempt to identify individuals with impaired urinary continence, i.e., reduced ability to maintain urine in a socially appropriate manner .3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure nursing staff followed professional standards of practice when flushing a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed (R237). Staff did not check blood return prior to flushing R237's PICC. Evidenced By: The Facility follows their Pharmacies Policy and Procedure entitled Central Vascular Access Device (CVAD) Flushing and Locking dated 6/1/24, it documents the following in part: .Considerations: 1. Central vascular access devices (CVADs) include: 1.1 Peripherally inserted central catheter (PICC) .4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R7) reviewed for hospice. R7's current hospice plan of care and visit notes were not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. This is evidenced by: The facility's Hospice Program policy, dated 10/2024, states, in part: .7. Identify a member of the IDT (interdisciplinary team) who is responsible for working with the hospice representative. This person's responsibilities include: .d. Ensuring the appropriate documents are readily available. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 31 residents. Surveyor observed milk left out for the duration of lunch service without any way to keep it cold and the milk temperature was 58 degrees. Surveyor observed DM G (Dietary Manager) not follow manufacturer's recommendations for use while utilizing the 3-compartment sink. Surveyor observed open food to have been removed from the original container with no expiration date and no open date. Surveyor observed a dented can in circulation. Surveyor observed the facility's mixer and meat slicer to be stored unclean. Evidenced by: Example: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 2 residents (R19) out of a total sample of 15. R19 had facial hair and requires assistance with shaving. This is evidenced by: R19 was admitted to the facility on [DATE] with diagnoses that include, in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side (Paralysis and Weakness following a Stroke), Other Reduced Mobility, Unspecified Lack of Coordination, and Weakness. R19's quarterly Minimum Data Set (MDS) with a target date of 1/10/24 indicates in part: Section C: A Brief Interview for Mental Status (BIMS) of 5, indicating R19 has a severe cognitive impairment. Section GG: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that, based on the comprehensive assessment of a resident, the residents receive treatment and care in accordance with professional standards of practice. This had the potential to affect 1 out of 15 residents reviewed (R20). R20 had a fall. LPN F (Licensed Practical Nurse) moved R20 off of the floor with an obvious injury and without a thorough assessment by a Registered Nurse (RN). Evidenced by: Facility policy, entitled Assessing Falls and Their Causes Guideline, effective 9/2023, includes: . After a fall- If a resident . found on floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to head, neck, spine, and extremities. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid . [...]

Inspectors wroteBased on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 12 residents reviewed for pain (R9). R9 voiced concerns regarding her pain regime not being effective, her physician orders not being followed, and the facility not having her medications in house at times. R9's Medication Administration Record (MAR) indicated that R9 missed doses of her pain medication and that her pain often reaches high levels. Staff interviews indicated staff were not utilizing the facility's contingency stock and R9 went without her pain medications. Evidenced by: Facility policy, entitled Pain Assessment and Management, effective 9/2023, includes: . [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor behaviors and symptoms of mental illness for 1 of 6 sampled residents out of a total sample of 15 (R26). R26 was diagnosed with major depressive disorder and is prescribed and administered Sertraline without targeted behavioral monitoring or use of non-pharmaceutical interventions to support or understand them or to prevent, relieve, or accommodate distress. This is evidenced by: The facility policy titled, Behavior Assessment and Monitoring, with a last approved date of 4/2023, includes, in part: Policy Interpretation and Implementation .Management - 1. The staff will identify and discuss with the practitioner situations where non-pharmacologic approaches are indicated, and will institute such measures to the extent possible. Monitoring .2. [...]