The Columns Rehabilitation and Healthcare Center

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 93.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medications had a Gradual Dose Reduction (GDR) completed for 1 resident (Resident #26) of 5 (#8, #13, #26, #40, #87) residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #96) of 1 resident reviewed for transfer/discharge. The total sample size was 30.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide care and services that meet professional standards of quality, by failing to accurately assess 1 resident (Resident #87). The total sample size was 30 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. The sample size was 30. The facility failed to ensure: Enhance Barrier Precautions (EBP) were implemented and utilized for Resident #10; andProper hand hygiene and gloving were performed throughout Resident #10's wound care treatment.

Inspectors wroteBased on record review and interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner for falls. The facility failed to provide documentation of evidence of its ongoing facility QAPI program. This deficient practice had the potential to affect 85 residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Nursing carts were free of loose pills for 1 (Cart A) of 2 (Cart A and Cart B) carts reviewed, and 2. Nursing carts were free of expired supplies for 1 (Cart B) of 2 (Cart A and Cart B) carts reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #51) of 26 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#45 and #70) of 2 (#45 and #70) sampled residents who received Advanced Beneficiary Notices of Non-Coverage (ABN).

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a dose reduction for 2 (#37 and #51) of 5 (#24, #37, #45, #50, and #51) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction.

Inspectors wroteBased on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #45) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a quarterly assessment for 1 (Resident #45) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (Resident #24) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail care and trimming for 1 (Resident #24) of 3 (Resident #17, Resident #24, and Resident #78) residents sampled for Activities of Daily Living (ADLs).

Inspectors wroteF692 Based on interview and record review the Facility failed to ensure that a Resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 1 (#69 ) of 3 (#39, #45, #69) sampled Residents reviewed for nutrition. Total sample size 26. The facility failed to ensure Resident #69 received ordered nutritional supplements with meals, assistance or encouragement with eating, and accurate documentation of meal intake.

Inspectors wroteBased on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to portion size to ensure the nutritional adequacy of the meal for all 10 residents who received a puree diet.

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 by failing to ensure: 1. Food was not open to air while stored in the pantry; and 2. Food serving scoop was not left inside sugar bin in direct contact with resident food items. This deficient practice had the potential to affect 84 residents who received meals served from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 3 (#2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to 1. Ensure Resident #2 was not physically abused by Resident #3; 2. Ensure Resident #3 was not physically abused by Resident #4; and 3. Ensure Resident #4 was not physically abused by Resident #3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the treatment of a skin tear was followed for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 90.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5) sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#46) out of a total of 23 sampled Residents, by failing to ensure she was free of facial hair.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure a resident (Resident #53) personal furniture was maintained in good sanitary condition. The sample resident size was 23.

Inspectors wroteBased on interview and record review the Facility failed to ensure their grievance policy and procedure was followed by failing to complete a grievance for 1 (#62) of 23 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered care plan for recurrent Urinary Tract Infections (UTI) for 1 (#25) of 1 (#25) residents reviewed for UTIs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 Residents (Resident #10 and Resident #21) of 23 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that food was properly stored in accordance with professional standards for food service safety. The facility failed to ensure that expired/outdated items were not available for resident consumption.