Columbia Post Acute

In the surveyor’s words

From the most serious findings on record at Columbia Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 10, 2025

  Based on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when facility staff administered an incorrect dosage of Morphine to the resident. The census was 67. 1. Review of the facility's Administering Medications policy, dated 04/2019, showed staff are directed as follows: -Medications are administered in accordance with prescribed orders; -Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; -The individual who administers the medication should check the label three times to verify the right resident, right medication, right dosage, right time, and right… […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2023

  Based on observation, interviews, and record reviews, the facility staff failed to wear hairnets and beard guards, to ensure the ice machine drained through an air gap, to maintain the kitchen in a clean and sanitary manner, to store food in a manner to prevent outdated usage and cross contamination, and to perform handwashing when appropriate. These failures had the potential to affect all residents. The census was 64. 1. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed hairnets and beard guards are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. […]

• No harm, potential for more than minimal, patternF695May 7, 2026

  Based on observation, interview, and record review, facility staff failed to obtain physician ordered settings for Continuous Positive Airway Pressure (CPAP) machine (non-invasive mechanical ventilation device) for three residents (Residents #66, #22 and #30) of three sampled residents who required the use of a CPAP. The facility census was 62.1. Review of the facility's policy titled CPAP/Bi-level positive airway pressure (BiPAP), non-invasive mechanical ventilation machine, Support, dated March 2015, showed staff to document the following in the resident's medical record: -Time CPAP started and duration; -Mode and settings for CPAP; -How resident tolerates CPAP therapy; -Oxygen saturation during CPAP therapy. […]

• No harm, potential for more than minimal, patternF657Nov 15, 2024

  Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for seven residents (Resident's #5, #13, #14, #27, #29, #35, and #40) out of 25 sampled. The census was 66. 1. Review of the facility's policy Care Plans, Comprehensive Person Centered, dated March 2022, showed care plans are developed within seven days of completion of the required MDS (Minimum Data Set), a federally mandated assessment tool (Admission. Annual, or Significant Change of Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. […]

• No harm, potential for more than minimal, patternF909Nov 15, 2024

  Based on observation, interview and record review, facility staff failed to conduct regular entrapment assessments for seven (Resident #5, #13, #14, #17, #29, #35 and #40) out of seven sampled residents who used bed rails . The facility census was 66. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. Regardless of mattress, type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are with the safety dimensions established by the Food and Drug Administration (FDA). […]