Resident C, who has moderate cognitive impairment and requires substantial help with transfers and toileting, developed an unstageable pressure ulcer on the right heel. The wound became infected, requiring antibiotics and specialized dressing changes.
But staff repeatedly skipped treatments and medications.
On September 1, nurses failed to document giving the 4 a.m. dose of clindamycin, an antibiotic prescribed every six hours for the wound. The resident's medication record shows a blank where the dose should have been recorded.
The wound care proved equally inconsistent. On September 26, when doctors ordered daily dressing changes with medical honey and calcium alginate, no staff member completed the treatment during the entire 12-hour day shift from 6 a.m. to 6 p.m.
A second antibiotic course fared no better. Resident C was prescribed cephalexin every eight hours starting October 6. Staff missed the 8 p.m. dose on October 10 and the noon dose on October 11, leaving gaps in the treatment record.
The wound care deteriorated further in mid-October. Doctors ordered twice-daily dressing changes with wound cleanser and gauze wrapping. Staff skipped treatments on October 16, October 18, and October 21.
Their documented reasons revealed a troubling pattern. On October 16 and 18, staff wrote they couldn't complete the treatment because "the resident was sleeping." On October 21, they cited "the resident's condition" and noted the resident was "unavailable."
The facility had also ordered Resident C to be turned and repositioned every two hours to prevent additional pressure ulcers. But Certified Nurse Aide 3 told inspectors on November 13 that Resident C "was not a resident who needed to be turned and repositioned every 2 hours."
The aide verified this belief by checking the assignment form, which indeed failed to list Resident C for repositioning.
The Director of Nursing contradicted this assessment during her own interview that same day. She confirmed Resident C was supposed to be turned and repositioned every two hours. She said the treatments "should have been completed as ordered" and that medication and treatment records "should not have been left blank."
Regarding residents who were sleeping, she said staff "should have attempted to wake the resident" to provide necessary care.
The facility's confusion about basic care protocols extended to policy gaps. The Assistant Administrator acknowledged on November 13 that Columbia Healthcare Center "did not have a policy related to following Physician's Orders."
However, he said "it would be their policy to follow orders."
Resident C's care plan, dated October 21, specifically addressed "impaired mobility related to right foot osteomyelitis" and included the intervention to turn and reposition every two hours. Another care plan from October 16 targeted "right heel infection" with the intervention to "administer antibiotics as ordered by the physician."
The missed treatments occurred despite clear documentation in the resident's record. Resident C has type 2 diabetes and gout, conditions that can complicate wound healing and increase infection risks.
The September 29 assessment showed Resident C had moderate cognitive impairment and was not enrolled in a turning and repositioning program, despite the medical need documented in care plans.
Federal inspectors reviewed four residents for quality of care issues. Only Resident C experienced failures to follow physician orders for medications and treatments.
The inspection followed a complaint filed with state health officials. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs. The findings become public 14 days after Columbia Healthcare Center receives the inspection report.
For Resident C, the consequences of missed antibiotics and delayed wound care remain documented in a clinical record that shows gaps where treatment should have occurred. The infected heel that required twice-daily attention instead received sporadic care when staff deemed the resident available and awake enough to disturb.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Columbia Healthcare Center from 2025-11-13 including all violations, facility responses, and corrective action plans.