Columbus Healthcare Center

Inspectors wroteBased on record review, observation, resident and staff interviews, and facility policy review, the facility failed to implement new safety interventions after a resident fall. This affected one resident (#42) of four residents reviewed. The facility census was 88.

Inspectors wroteBased on record review, and staff interviews the facility failed to ensure medications were obtained in a timely manner and were administered as per orders. This affected one resident (#89) out of three residents reviewed for medications administered. The facility census was 88.

Inspectors wroteBased on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure call lights were kept within resident's reach. This affected one resident (#2) out of three residents reviewed for call lights. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure non-pharmacological interventions were utilized and adequate assessments of pain were completed prior to administering as needed pain medications. This affected one (Resident #94) of three residents reviewed for pain management. The census was 93. Findings Include:Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included alcoholic cirrhosis of the liver with ascites, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, other chronic pain, polyneuropathy, hyperlipidemia, hypertension, alcohol dependence, morbid obesity, insomnia, restlessness and agitation, mood disorder, vitamin D deficiency, and unspecified convulsions. [...]

Inspectors wroteBased on medical record review, staff interview, and review of a facility staff schedule, the facility failed to provide adequate staffing to meet the behavioral safety needs of all residents. This affected one (Resident #41) of three residents reviewed for behavior management. The census was 93. Findings Include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, systemic inflammatory response syndrome, borderline personality disorder, postural orthostatic tachycardia, disorientation, mood disorder, suicidal ideations, convulsions, personal history of other mental and behavioral disorders, conversion disorder, anxiety disorder, headache, bipolar disorder, post-traumatic stress disorder, insomnia, muscle weakness, muscle wasting, dysphagia, and fibromyalgia. [...]

Inspectors wroteBased on medical record review, staff interview, review of the fall investigation, review of hospital records, hospital staff interview, and review of facility policy, the facility failed to ensure that staff followed the established care plan and safety protocols for Resident #99 during the provision of care to prevent an incident/accident resulting in the resident falling from the bed to the floor sustaining serious injuries. This resulted in Actual Harm on 03/26/26 when Certified Nursing Assistant (CNA) #333 had provided perineal care independently to Resident #99 while the resident was in bed. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store food in a safe and sanity manner. This had the potential to affect all 95 residents admitted to the facility. The facility census was 95.

Inspectors wroteBased on interview and document review the facility failed to ensure kitchen equipment was maintained in safe operating condition. This had the potential to affect all 95 residents residing within the facility. The facility census was 95.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure residents had a comprehensive care plan that reflected their current status. This affected four residents (#15, #45, #75, and #96) of 29 sampled residents. The facility census was 95 residents.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to have interventions in place to prevent falls for Residents #52, #15, #97, #103, and #94. Additionally, the facility failed to complete a thorough investigation following a fall for Resident #88. This affected six residents (#52, #15, #97, #88, #103, and #94) of 11 residents reviewed for falls. The facility census was 95 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide showers per resident choice. This affected one (Resident #53) of two residents reviewed for choices. The facility census was 95 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain clean and sanitary bed curtains. This affected one (Resident #45) of three residents reviewed for environment. The facility census was 95 residents.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to provide nail care for Residents #66, and #88 who were dependent on staff for care. This affected two residents (#66 and #88) of seven residents reviewed for activities of daily living. The facility census was 95.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure a midline dressing was changed as ordered. This affected one (Resident #53) of one resident reviewed for intravenous access line care. The facility census was 95 residents.

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to provide timely treatment to maintain Resident's #1 hearing abilities. This effected one resident (#1) of one resident reviewed for hearing issues. The facility's census was 95. Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff supervision for mobility and self care. [...]

Inspectors wroteBased on staff interview, medical record review, and facility policy review, the facility failed to obtain weekly weights as ordered for Resident #52. This affected one resident (#52) of seven residents reviewed for nutritional issues. The facility census was 95. Resident #52 was admitted [DATE] and has diagnoses that include chronic obstructive pulmonary disease, severe protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident used a wheelchair for mobility and had severe cognitive impairment. Further review of Resident #52's medical record revealed an order for weekly weights written on 12/04/25. Further review of Resident #52's medical record demonstrated there were no recorded weights for the timeframe between 12/17/25 and 01/08/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change oxygen tubing as required and failed to ensure the humidifier solution was not empty. This affected one resident (#1) of four residents reviewed for respiratory care. The facility's census was 95. Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff assistance with mobility and self-care assistance. [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to provide services to treat a resident's anxiety. This affected one (#65) of one resident reviewed for behavioral health. The facility census was 95. Record review for Resident #65 revealed this resident was admitted to the facility on 01/14 26 with diagnoses including: multiple fractures of the bilateral ribs, anxiety disorder, fracture of the pelvis, fracture of the right lower leg, depression, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require hygiene and mobility assistance from staff. Review of the care plan dated 01/14/26 revealed Resident #65 is at risk of impaired psychosocial well-being. [...]

Inspectors wroteBased on interview, record review, and review of the social service director job description, the facility failed to timely arrange and follow up on guardianship for Resident #78 according to the expert evaluation. This affected one resident (#78) of one resident reviewed for guardianship. The facility census was 95.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered timely for two residents (#101 and #103) of two residents reviewed for timely administration of medications. The facility census was 95.

Inspectors wroteBased on resident record review, interview, and facility policy review, the facility failed to follow parameters for blood pressure medication. This affected one resident, Resident #58, of six reviewed for unnecessary medications. The facility census was 95.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to store medications appropriately when found at Resident #45's bedside. This affected one resident (#45) of one resident observed for medication storage. The facility census was 95 residents.

Inspectors wroteBased on closed medical record review, hospital record review, staff interview and policy review, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #88. The facility failed to ensure changes in the resident's medical condition were comprehensively assessed, that high blood glucose levels were communicated to the medical provider, and individualized interventions were implemented. This resulted in Actual Harm with subsequent hospitalization when on 06/23/25 Resident #88 had a high blood glucose reading of 471 milligrams per deciliter (mg/dL) (normal ranges from 80 to 130 mg/dL in adults with type two diabetes) requiring notification to a medical provider, which was not completed. [...]

Inspectors wroteBased on record review, resident representative interview, staff interview, and review of facility policy, the facility failed to notify the resident's representative of a resident's change in care. This affected one (Resident #21) of four residents review for notification of change. The facility census was 98.

Inspectors wroteBased on interview with hematology oncology department, interview with pharmacist, staff interviews, record reviews, and review of facility policy, the facility failed to ensure consistent continuity of care between outside providers including implementing physician orders from outside provider and timely communication and follow up with outside provider. This affected two (Residents #46 and #55) of three residents reviewed for quality of care. The facility census was 98.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). This affected two (#64 and #80) of four residents observed for medication administration. There were 29 opportunities with four medication errors for a medication error rate of 13.7%. The facility census was 98.

Inspectors wroteBased on observations, record review, policy review, and staff interview the facility failed to implement a comprehensive and individualized pressure ulcer prevention program to ensure adequate interventions were in place to promote healing and prevent new ulcers from developing. Actual Harm occurred on 08/13/24 when Resident #57, who exhibited severe cognitive impairment, had a current pressure ulcer present and required substantial/maximal assistance for bed mobility was assessed to have a new in-house developed pressure ulcer. The resident was assessed to have a deep tissue injury (Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the right ischium/hip that developed due to the lack of adequate interventions including turning and repositioning. [...]

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living was provided with the necessary services to maintain good personal hygiene. This affected one of five sampled residents (Resident #57). The facility census was 96.

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to follow up on dietician recommendations to ensure a resident maintained acceptable parameters of nutritional status, including body weight. This affected one of five sampled residents (Resident #93). The facility census was 96.

Inspectors wroteBased on observations, policy review, medical record review, and staff interview, the facility failed to develop/implement infection control policies to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections. This affected two of five sampled residents (Residents #3 and #57). The facility census was 96.

Inspectors wrote3. Review of the medical record for Resident #20 revealed an admission date of 03/18/14 with diagnoses including type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, contracture of muscle in left hand, contracture of left ankle, dementia, reduced mobility, and need for assistance with personal care. Review of the MDS assessment for Resident #20 dated 04/05/24 revealed the resident was cognitively impaired and depended on staff assistance with eating. Review of the physician's orders for Resident #20 revealed orders dated 02/12/24 for the resident to be weighed weekly on Mondays and offer fortified pudding with lunch and dinner and an order dated 04/01/24 for a pureed textured diet. Review of the weight record for Resident #20 revealed the following dates/weights: -11/08/23 weight of 177 lbs. [...]

Inspectors wroteBased on review of staff schedules, review of the facility assessment, staff interview, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight consecutive hours a day. This had the potential to affect all residents residing in the facility. The facility census was 96 residents.

Inspectors wroteBased on employee file review and staff interview, the facility failed to ensure State Tested Nursing Assistants (STNAs) received annual performance reviews and 12 hours of continuing education annually. This had the potential to affect all residents residing in the facility. The facility census was 96 residents.

Inspectors wroteBased on observation, staff interview and review the facility policy the facility failed to ensure loose improperly stored medications were discarded and failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure safe and sanitary storage of food items in the kitchen. This affected all residents residing in the facility. The facility census was 96 residents.

Inspectors wroteBased on observation, staff interview, review of pest control logs, and review of the facility policy, the facility failed to ensure proper pest control interventions were in place in the kitchen. This affected all residents residing in the facility. The facility census was 96 residents.

Inspectors wroteBased on review of Resident Council meeting minutes, resident interviews, staff interviews, and facility policy review, the facility failed to timely respond to resident concerns. This affected 16 facility-identified (Residents #3, #8, #13, #17, #22, #26, #30, #38, #42, #43, #44, #46, #51, #52, #74, #79) who attended the Resident Council meetings. The facility census was 96 residents.

Inspectors wroteBased on medical record review, review of Self-Reported Incidents, staff interview, and review of the facility policy, facility failed to ensure resident care plans were updated regarding behavioral changes. This affected one (Resident #81) of two residents reviewed for behaviors. Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility also failed to ensure care conferences were completed for residents. This affected five (Residents #14, #30, #73, #78, #88) of five residents reviewed for care conferences. The census was 96 residents.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and facility policy review, the facility failed to ensure residents who were dependent on staff assistance with personal hygiene received routine nail care. This affected five (Residents #14, #20, #24, #50, #92) of seven residents reviewed for activities of daily living (ADLs.) The facility also failed to ensure dependent residents received routine bathing assistance. This affected two (Residents #27 and #92) of seven residents reviewed for ADLs. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview the facility failed to ensure splints were placed appropriately and orders for fitting of diabetic shoes were completed timely. This affected four (Residents #20, #24, #14 and #47) of four residents reviewed for range of motion. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to follow infection control practices for residents with dressings to peripherally inserted central catheters (PICC) line site. This affected one (Resident #87) of one resident reviewed for intravenous (IV) therapy. The facility also failed to ensure medications were administered using proper infection control practices. This affected two (Residents #5 and #27) of five residents observed for medication administration. The facility also failed to ensure staff wore proper personal protective equipment (PPE) when providing hands-on care to residents on enhanced barrier precautions (EBP) This affected two (Residents #24 and #43) of 25 facility-identified residents who required EBP. [...]

Inspectors wroteBased on medical record review, observation, resident interviews and the facility failed to ensure residents were dressed in an appropriate and dignified manner. This affected one (Resident #43) of two residents reviewed for dignity. The facility census was 96 residents.

Inspectors wroteBased on observation, family and staff interview, facility failed to ensure call lights were within reach for one (Resident #88) of one resident reviewed for call lights. The facility also failed to ensure resident choice to go outside when not medically contraindicated. This affected one (Resident #30) of two residents reviewed for dignity and respect. The facility census was 96 residents.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure accurate advanced directives and code status were reflected in the resident medical record. This affected two (Residents #14 and #30) of two reviewed for advanced directives. The facility census was 96 residents.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to notify the primary care physician of resident blood glucose level outside of the physician-ordered parameters. This affected one (Resident #27) of one residents reviewed for insulin. Additionally, the facility failed to notify resident representatives of discontinuation of enteral tube feeding. This affected one (Resident #88) of eight residents reviewed for nutrition. The facility census was 96 residents. Findings Include: 1. [...]

Inspectors wroteBased on medical record review, observation, resident representative interview, and staff interview, the facility to ensure privacy curtains were kept clean. This affected one (Resident #88) of 31 sampled residents. The facility census was 96 residents. Findings Include: Review of the medical record for Resident #88 revealed an admission date of 12/13/23 with diagnoses including hemiplegia and hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness and cognitive communication. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 05/03/24 revealed the resident was cognitively impaired and required assistance with activities of daily living, (ADLs.) Observation on 06/03/24 at 11:20 A.M. revealed Resident #88's privacy curtain was dirty with brown splatter and food crumbs stuck to it. Interview on 06/04/24 at 9:13 A.M. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, review of Pre-admission and Resident Review (PASARR) results letter, and facility policy review, the facility failed to educate, offer, or implement Level II services for residents. This affected one (Resident #39) of two residents reviewed for PASARR screenings. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to timely evaluate and treat a rectal fistula, failed to timely schedule an outside gastroenterology (GI) follow-up appointment, and failed to ensure precertification for hospice services was completed. This affected three (Residents #11, #64, and #73) of 31 residents sampled. The facility census was 96 residents.

Inspectors wroteBased on medical record review, resident representative interview, and staff interview, the facility failed to ensure timely follow up for ophthalmology (vision) services. This affected one (Resident #88) of one resident reviewed for ophthalmology services. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to comprehensively assess resident pressure ulcers upon admission/readmission to the facility. This affected three (Residents #24, #27, #43) of six residents reviewed for pressure ulcers. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure incontinence care was provided timely and upon request. This affected one (Resident #14) of one resident reviewed for incontinence care. The facility census was 96 residents.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure oxygen equipment was stored appropriately and oxygen nasal cannula tubing was changed as ordered by the physician. This affected two (Residents #27 and #64) of two residents reviewed for respiratory services. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/15/24 with diagnoses including acute kidney failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), severe morbid obesity, diabetes mellitus, gastro-esophageal reflux disease, hypertension, hyperlipidemia, adult failure to thrive, history of malignant neoplasm of prostate and osteoarthritis. [...]

Inspectors wroteBased on medical record review, hospital staff interview, staff interview, and review of the facility policy, the facility failed to ensure residents were notified in writing of proposed discharge from the facility. This affected one (Resident #10) of three residents reviewed for discharge to the hospital. The census was 97.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide adequate resident supervision and assistance resulting in a fall with major injury. Actual Harm occurred on 01/19/24 when Resident #1, who was identified at risk for falls, assessed to have cognitive impairment, and required supervision while smoking, exited the facility through two sets of locked doors, to the facility's outdoor smoking area with a cigarette and the intention of helping Receptionist #100 shovel snow due to inclement weather. Once Receptionist #100 discovered the resident was outside, the resident was instructed to return to her room. The resident entered the facility while wearing wet footwear (from snow) and subsequently slipped on the tile floor. The resident sustained a right distal radius and ulnar fracture. [...]

Inspectors wroteBased on medical record review, staff interview, and observation, the facility failed to ensure nutritional interventions were implemented timely, nutritional recommendations were addressed timely, and failed to ensure diet orders were followed as ordered. Actual harm occurred when Resident #52, who was assessed as a 12 percent weight loss in 30 days, did not have nutritional recommendations addressed timely and nutritional interventions were not implemented timely. Additionally, actual harm occurred when Resident #63, who was assessed as a 21% weight loss in 180 days, did not have nutritional interventions implemented timely and did not receive the appropriate diet. This affected two residents (#52 and #63) of seven reviewed for weight loss. The facility census 92.

Inspectors wroteBased on observations, staff interviews, resident interviews and policy and procedure review, the facility failed to ensure staff wore personal protection equipment appropriately. This had the potential to affect all 92 residents in the facility. The census was 92.

Inspectors wroteBased on observations, review of facility policy, interviews with residents and staff, the facility failed to ensure residents were permitted to eat in the dining room to promote well-being and homelike environment. This affected 87 of 87 residents who received food from the kitchen. The facility identified five residents who do not receive food from the kitchen.

Inspectors wroteBased on review of resident council meeting minutes and review of facility policy, staff and resident interview, the facility failed to follow up on resident council requests surrounding smoke breaks. This had the potential to affect 25 of 25 residents the facility identified as being smokers. The facility census was 92.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's physician of a significant weight change and failed to notify a physician of a weight change related to edema. This affected three (#3, #41 and #52) of seven residents reviewed for nutrition and one (#59) of one resident reviewed for edema. The facility census was 92.

Inspectors wroteBased on medical record review, policy reviews and staff interviews, the facility failed to ensure the pharmacy recommendations were acted on timely. This affected three (#35, #59 and #63) of five residents reviewed for unnecessary medications. The facility census was 92.

Inspectors wroteBased on observation, review of facility policies and staff interviews, the facility failed to store medications properly and in a manner that deters theft or inappropriate ingestion. This affected three residents (#32, #59, and #71) and had the potential to affect all 41 of 41 residents who reside on the 200 hall and 300 hall. The census was 92.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean environment for residents. This affected four (#25, #29, #32 and #80) of 22 resident's rooms observed. The facility census was 92.

Inspectors wroteBased on medical record review, facility documents review, and staff interview, the facility failed to notify residents or their representatives in writing as to the reason they were being transferred to the hospital. This affected three (#32, #75 and #87) of three residents who were reviewed for hospitalization. The census was 92.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to develop a comprehensive care plan to address a resident experiencing delusions. This affected one (#86) of two residents reviewed for mood and behavior. The facility census was 92.

Inspectors wroteBased on medical record review, observations, staff interviews, procedure manual review and policy review, the facility failed to provide care and services for pressure ulcer treatments as ordered to promote healing. This affected three (#7, #32 and #71) of five residents reviewed for pressure ulcers. The facility census was 92.

Inspectors wroteBased on observations, medical record review and staff interview, the facility failed to ensure a resident was wearing a physician ordered hand splint. This had the potential to affect one (#76) of one resident reviewed for assistive devices. The facility census was 92.

Inspectors wroteBased on observations, medical record reviews, review of policy, resident and staff interviews, the facility failed to ensure residents received a meal prior to leaving for their dialysis appointment and coordinated care with the dialysis center. This affected two (#48 and #75) of two residents reviewed for dialysis. The census was 92.

Inspectors wroteBased on observations, policy review, medical record review and staff interviews, the facility failed to ensure resident's medication administration had a medication error rate of less than 5%. The facility was observed to have two medication errors in 35 opportunities for an error rate of 5.7%. This affected two (#32 and #246) of five residents observed for medication administration.

Inspectors wroteBased on medical record review, policy review and staff interviews, the facility failed to ensure a resident received his cancer medicine as ordered. This affected one (#75) of five residents reviewed for medications. The census was 92.

Inspectors wroteBased on medical record review, policy review and staff interviews, the facility failed to timely obtain physician ordered laboratory test and report the results of the laboratory test to the physician. This affected one (#52) of one resident reviewed for urinary tract infections. The facility census was 92.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to provide appropriate adaptive feeding equipment to residents. This affected one resident (Resident #25) of twelve residents with adaptive feeding equipment. The census was 92.