Inspection Reports for Medicalodges Columbus
101 LEE AVENUE, PO BOX 351, KS, 66725-351
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 17, 2019 found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections, including one on January 10, 2019, cited multiple deficiencies related mainly to infection control, care planning, medication management, and environmental sanitation. Earlier complaint investigations were not listed in the available reports, and no fines, immediate jeopardy findings, or license actions were noted. Previous corrective actions included staff education, removal of contaminated items, and improvements in resident care plans and medication monitoring. The inspection history shows improvement over time, with the facility correcting earlier cited issues and maintaining compliance in the latest survey.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
35 residents
Based on a January 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 17, 2019
Visit Reason
A second revisit survey was conducted on 4/17/19 for all previous deficiencies cited on 2/21/19 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 3/1/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: Mar 1, 2019
Inspection Report
Plan of Correction
Deficiencies: 14
Jan 29, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report (2567) dated 2019-01-10. It outlines corrective actions to address identified issues and maintain compliance.
Findings
The Plan of Correction details multiple corrective actions including removal and replacement of contaminated or damaged resident items, education of staff on infection control and care plan development, audits and monitoring of compliance, and updates to resident care plans and medication management.
Severity Breakdown
E: 5
D: 5
F: 2
G: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Improper storage and labeling of resident hairbrushes and toothbrushes, and presence of dirty fall mats | E |
| Care plans for residents #30 and #134 were reviewed and updated | D |
| Care plan reviewed and revised for resident #28 to prevent weight loss | D |
| Therapy screening and restorative program development for resident #21 | D |
| Chemical hazards accessible to residents were removed and staff educated | E |
| Medication review and education related to weight loss for resident #26 | G |
| Care plan updated for resident #134 respiratory needs and physician orders clarified | D |
| Staff in-service training on direct care scheduling and education requirements | F |
| Discontinuation and review of PRN medications for resident #21 | D |
| Psychotropic medication assessments completed and staff educated | D |
| Medication carts audited and expired medications removed | E |
| Opened kitchen items exceeding 72 hours removed and dietary staff trained | F |
| Replacement of contaminated resident care items and infection control education | E |
| Removal of items stored on floor in restorative closet and central supply room | E |
Report Facts
Deficiencies cited: 14
Completion date: Feb 9, 2019
Education completion date: Jan 31, 2019
Medication cart audits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction | |
| Lacey Hunter | Modified Plan of Correction |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 15
Jan 10, 2019
Visit Reason
Annual health resurvey of Medicalodges Columbus to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including sanitary conditions, baseline care planning, care plan revisions, range of motion maintenance, accident hazard prevention, nutrition and hydration maintenance, respiratory care, nursing staff sufficiency, nurse aide training, medication management, food safety, infection control, and environmental maintenance.
Severity Breakdown
SS=E: 6
SS=D: 5
SS=G: 1
SS=F: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to maintain a sanitary, orderly, and comfortable interior for 5 of 28 rooms and a shower room. | SS=E |
| Failed to develop and implement baseline care plans within 48 hours of admission for residents #30 and #134. | SS=D |
| Failed to review and revise care plan for resident #28 to prevent significant weight loss. | SS=D |
| Failed to provide appropriate treatment and services to maintain range of motion for resident #21. | SS=D |
| Failed to keep hazardous chemicals locked and out of reach of confused residents. | SS=E |
| Failed to ensure resident #28 maintained adequate nutrition, resulting in significant weight loss. | SS=G |
| Failed to provide necessary respiratory care and services for resident #134 including clarifying physician orders and proper cleaning of inhalation equipment. | SS=D |
| Failed to have sufficient nursing staff to provide care based on residents' individualized needs. | SS=F |
| Failed to ensure direct care staff employed over a year had at least 12 hours of in-service education. | SS=E |
| Failed to monitor unused prn medication (Tramadol) for resident #21 to prevent unnecessary medication use. | SS=D |
| Failed to complete psychotropic medication assessments (AIMS or DISCUS) for residents #19 and #21 after initiation of antipsychotic medications. | SS=D |
| Failed to properly label insulin pens with dosage instructions and open dates, failed to remove expired medications, and failed to lock medication cart during medication pass. | SS=E |
| Failed to store and prepare food under sanitary conditions including outdated food items and damaged kitchen equipment. | SS=F |
| Failed to provide proper infection control practices including improper storage of dirty linens, bedpans, urine collection containers, and trash cans in resident rooms. | SS=E |
| Failed to maintain a safe, sanitary, and comfortable environment in the central supply room and restorative closet with items stored on the floor. | SS=E |
Report Facts
Deficiencies cited: 15
Weight loss percentage: 10.49
Resident census: 35
Staff training hours: 6.25
Staff training hours: 7.25
Staff training hours: 8.25
Staff training hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Verified failure to monitor unused prn medications and lack of system for monitoring |
| Staff I | Licensed Nursing Staff | Verified lack of psychotropic medication assessments for resident #19 and #21 |
| Staff R | Licensed Nursing Staff | Verified medication cart left unlocked and expired medications not removed |
| Staff S | Licensed Nursing Staff | Left medication cart unlocked during medication pass |
| Staff G | Direct Care Staff | Reported improper storage of urine collection items and bath basins |
| Staff F | Direct Care Staff | Verified items stored on restorative closet floor |
| Staff Q | Dietary Staff | Reported food should be held for only 3 days and dated |
| Staff X | Dietary Staff | Reported responsibility to monitor food expiration dates |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 1, 2017
Visit Reason
The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 1, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for the facility identified as ASPEN, State ID N011003.
Findings
No deficiencies were cited in the referenced inspection report, as indicated by the Plan of Correction.
Deficiencies (1)
| Description |
|---|
| No deficiencies cited |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 10, 2016
Visit Reason
The licensure survey was conducted to assess compliance for the facility's licensing requirements.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 10, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for the facility ML Columbus ALF dated 08/10/2016.
Findings
No deficiencies were cited in the referenced inspection report dated 08/10/2016.
Report Facts
Plan of Correction completion date: Aug 10, 2016
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 26, 2016
Visit Reason
The health survey was conducted as an annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 26, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a previous inspection report for the facility identified as ASPEN, State ID N011003.
Findings
No deficiencies were cited in the referenced inspection report dated 04/26/2016.
Deficiencies (1)
| Description |
|---|
| No deficiencies cited. |
Inspection Report
Re-Inspection
Deficiencies: 2
Mar 20, 2015
Visit Reason
This report documents a revisit inspection to verify that previously identified deficiencies have been corrected and to record the dates when corrective actions were completed.
Findings
The revisit report confirms that the deficiencies previously cited under regulations 26-41-202 (a) and 26-41-204 (i) were corrected as of 03/20/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-41-202 (a) |
| Deficiency related to regulation 26-41-204 (i) |
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 2
Mar 18, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with regulatory requirements for an assisted living facility.
Findings
The facility failed to develop negotiated service agreements that included descriptions of services provided and identification of service providers for two residents. Additionally, the facility failed to provide care according to acceptable standards for a resident with diabetes, not following the hypoglycemia protocol adequately during multiple low blood sugar episodes.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a negotiated service agreement including description of services and identification of providers for residents #1 and #3. | SS=D |
| Failed to provide care according to acceptable standards and facility hypoglycemia policy for resident #1. | SS=D |
Report Facts
Census: 15
Low blood sugar readings: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff B | Verified treatment provided to resident #3 and reported on wellness monitoring and physician knowledge | |
| direct care staff C | Reported on application of compression hose and leg wraps for resident #3 | |
| direct care staff D | Assisted resident #1 with finger stick blood sugar test | |
| administrative staff | Reported resident #1 received wellness monitoring services since admission |
Inspection Report
Follow-Up
Deficiencies: 3
Jan 22, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that previously identified deficiencies were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
Inspection Report
Plan of Correction
Deficiencies: 4
Jan 22, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Columbus addressing deficiencies identified in a prior survey (Event ID DPW411). The plan outlines corrective actions to maintain compliance with participation requirements.
Findings
The facility plans to improve quality assurance efforts, implement adequate care plan interventions for residents with weight changes, and re-educate staff on behavior monitoring protocols to prevent unnecessary medication use. Weekly monitoring and monthly reporting to the Quality Assurance Committee are included.
Severity Breakdown
D: 2
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain substantial compliance with participation requirements. | — |
| Inadequate care plan interventions for residents exhibiting weight changes. | D |
| Inadequate interventions for residents exhibiting weight changes. | D |
| Inadequate behavior monitoring protocols and documentation to prevent unnecessary medication. | E |
Inspection Report
Enforcement
Deficiencies: 1
Jan 8, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Administrator | Named as facility administrator in the report |
| Irina Strakhova | Enforcement Coordinator | Author of the enforcement letter |
| Janice VanGotten | Regional Manager | Copied on the letter |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 3
Jan 8, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with previously cited deficiencies related to care planning, nutrition, medication monitoring, and behavior management.
Findings
The facility failed to revise care plans related to weight loss, failed to implement timely interventions to prevent continued weight loss, and failed to adequately monitor medications and behaviors for several residents. There were also failures in monitoring laboratory tests related to anticoagulant therapy and documenting behavioral interventions.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to revise care plan related to weight loss for resident #53. | Level D |
| Failed to develop and implement timely and effective interventions to prevent continued weight loss for resident #53. | Level D |
| Failed to monitor medications with behaviors and laboratory testing to ensure no unnecessary medication usage for residents #12, #31, #36, #24, and #51. | Level E |
Report Facts
Resident weight: 38
Residents sampled: 15
Weight loss percentage: 5
Weight measurements: 141.2
Weight measurements: 131.2
Weight loss events: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed nursing staff | Provided information on weight loss protocol and medication monitoring |
| Staff F | Dietary staff | Provided information on Red Napkin program and weight loss monitoring |
| Staff O | Direct care staff | Reported on resident assistance needs and behavior documentation |
| Staff I | Licensed nursing staff | Reported on behavior interventions and documentation practices |
| Staff B | Administrative nursing staff | Discussed behavior program and documentation expectations |
| Staff A | Administrative staff | Discussed weight loss monitoring and clarification of physician orders |
| Staff D | Consultant staff | Advised on behavior monitoring system and lab monitoring |
Inspection Report
Life Safety
Deficiencies: 1
Apr 10, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jul 10, 2014
Provider agreement termination date: Oct 10, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 21, 2013
Visit Reason
This is a post-certification revisit report to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The report confirms that deficiencies previously cited under regulations 483.25(c), 483.25(h), and 483.35(i) were corrected by 10/16/2013.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.35(i) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Follow-Up
Deficiencies: 1
Nov 21, 2013
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at Medicalodges Columbus.
Findings
The report confirms that the previously cited deficiency identified by regulation 28-39-158(g) with ID prefix S0640 was corrected as of 2013-10-16.
Deficiencies (1)
| Description |
|---|
| Deficiency previously reported under regulation 28-39-158(g) with ID prefix S0640 |
Report Facts
Deficiency correction date: Oct 16, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 3, 2013
Visit Reason
This document is a Plan of Correction submitted by Gran Villas Columbus in response to deficiencies cited in the related deficiency report (2567). The plan outlines corrective actions to address sanitary condition issues.
Findings
The facility was found to have sanitary condition deficiencies, specifically related to the cleanliness of the kitchen stove and kitchen area. Corrective actions include deep cleaning and maintenance of kitchen equipment and implementation of routine cleaning schedules.
Deficiencies (1)
| Description |
|---|
| Sanitary Conditions - kitchen stove and kitchen cleanliness |
Report Facts
Complete Date for corrective actions: Oct 14, 2013
Date of deep cleaning of kitchen: Oct 1, 2013
Date scheduled for stove deep cleaning: Oct 15, 2013
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 3, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report (Medicalodges Columbus 092413). It outlines corrective actions to address identified issues.
Findings
The facility plans to re-educate staff on pressure sore prevention and reporting, implement fall risk identification measures including alarms, and improve kitchen sanitation through deep cleaning and maintenance. Ongoing monitoring and reporting to the Quality Assurance committee are included.
Deficiencies (3)
| Description |
|---|
| Failure to properly treat and prevent pressure sores (F314-G) |
| Failure to maintain a safe environment free of accident hazards and proper supervision/devices (F323-D) |
| Failure to maintain sanitary food procurement, storage, preparation, and service (F371-F) |
Report Facts
Complete Date: Oct 14, 2013
Complete Date: Oct 8, 2013
Complete Date: Oct 16, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Adult Care Home Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 3
Sep 24, 2013
Visit Reason
This inspection was a health resurvey conducted to assess compliance with regulatory requirements related to pressure sore treatment, accident hazards prevention, and sanitary food preparation.
Findings
The facility failed to provide timely treatment and assessment for a resident-acquired pressure ulcer, failed to implement planned fall prevention interventions for a resident at high risk of falls, and failed to maintain sanitary conditions in the kitchen food preparation areas.
Severity Breakdown
SS=D: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to identify, adequately assess, and provide timely treatment to prevent and promote healing of a facility-acquired pressure ulcer for one resident. | SS=D |
| Failure to provide planned interventions to ensure a resident remained free of falls, including failure to properly use alarms and supervision. | SS=F |
| Failure to maintain clean food preparation areas in the kitchen, including accumulation of burned substances in ovens and stove, unclean hand washing sink, and grime on microwave. | SS=F |
Report Facts
Census: 44
Sample size: 19
Residents with pressure ulcers: 3
Fall risk assessment score: 15
Fall risk assessment score: 22
Pressure ulcer size: 1.5
Pressure ulcer size: 0.8
Bruise size: 3
Bruise size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Reported resident #51's pressure ulcer and conducted staff education on bandaid removal | |
| Certified nurse aide K | Discovered pressure ulcer on resident #51's outer right ankle | |
| Licensed nurse I | Acknowledged aides' responsibility for skin observation during showers | |
| Physician D | Physician | Debrided resident #51's pressure ulcer and assessed wound |
| Administrative nursing staff B | Reported on fall risk interventions and alarm use for resident #53 | |
| Direct care staff F | Assisted resident #53 with toileting and bed transfer; reported broken pressure sensor alarm | |
| Direct care staff H | Observed resident #53 ambulating without alarm | |
| Dietary staff C | Reported on kitchen cleaning schedule and need for thorough cleaning |
Inspection Report
Renewal
Census: 20
Deficiencies: 3
Sep 24, 2013
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with sanitary conditions and other regulatory requirements.
Findings
The facility failed to maintain clean food preparation areas in the kitchen, including ovens with burned substances and grime, an unclean hand washing sink, and a sticky microwave top, posing a risk of food borne illness to residents.
Deficiencies (3)
| Description |
|---|
| Two ovens had accumulation of burned substances and grime on interior doors and walls; two stove burners had a 2 inch accumulation of burned substance; stove knobs had grime buildup. |
| Hand washing sink in the kitchen contained an unclean tan colored stained area in the bowl. |
| Top of the microwave contained a sticky layer of grime. |
Report Facts
Census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff C interviewed about cleaning schedule |
Inspection Report
Follow-Up
Deficiencies: 7
Jul 3, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-06-11.
Findings
All previously reported deficiencies identified by regulation numbers 483.10(b)(11), 483.15(h)(2), 483.20(b)(1), 483.25(a)(3), 483.25(d), 483.25(l), and 483.25(m)(1) were corrected as of the revisit date.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.25(m)(1) |
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Jul 3, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Columbus addressing deficiencies identified in a prior inspection report (2567). It outlines corrective actions to maintain compliance with participation requirements.
Findings
The plan details corrective actions including staff training on mental health notifications, housekeeping and maintenance improvements, reassessment of residents' voiding patterns, personal hygiene care, urinary incontinence management, medication regimen monitoring, and medication administration training.
Severity Breakdown
E: 2
D: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide immediate notification of changes in resident's mental condition and inadequate staff training on such notifications. | E |
| Inadequate housekeeping and maintenance services to maintain sanitary and orderly conditions. | E |
| Failure to reassess 3-day voiding patterns for residents and provide individualized incontinence care plans. | D |
| Personal hygiene needs of resident not adequately addressed. | D |
| Inadequate education and training on urinary incontinence, catheter use, and urinary tract infection prevention. | D |
| Failure to monitor drug regimen monthly to prevent unnecessary medications and inadequate staff training on communication of medication issues. | D |
| Inadequate education and training on medication administration for licensed nursing personnel and certified medication aides. | D |
Report Facts
Deficiencies cited: 7
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 7
Jun 11, 2012
Visit Reason
The inspection was a health facility re-survey to evaluate compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify the physician of a resident's mental health deterioration, inadequate housekeeping and maintenance, incomplete comprehensive assessments for incontinence, failure to provide adequate ADL care, failure to prevent urinary tract infections by proper catheter and incontinence management, failure to monitor laboratory tests for Coumadin therapy, and medication administration errors.
Severity Breakdown
SS=D: 6
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to notify the physician when a resident demonstrated deterioration in mental health. | SS=D |
| Failure to maintain a homelike and clean environment, including dirty combs and brushes and stained carpeting. | SS=E |
| Failure to conduct comprehensive assessments for incontinence including a 3 day voiding pattern for three residents. | SS=D |
| Failure to provide grooming and hygiene assistance to a dependent resident, evidenced by long facial hair, broken and dirty fingernails, and yellow mattering to eyes. | SS=D |
| Failure to ensure a resident without catheter received appropriate treatment to prevent urinary tract infections and restore bladder function, including failure to provide toileting opportunities. | SS=D |
| Failure to monitor laboratory tests for Coumadin therapy, resulting in critical high PT/INR values and bleeding. | SS=D |
| Medication administration errors including giving medications with food when ordered on empty stomach and failure to rinse mouth after inhaler use. | SS=D |
Report Facts
Census: 39
Residents selected for review: 21
Medication pass opportunities: 55
Medication errors: 3
Medication error rate: 5.45
PT lab value: 21.5
INR lab value: 2.8
PT lab value: 35.9
INR lab value: 6.7
Duration without toileting opportunity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Direct care staff encouraging resident at noon meal | |
| Administrative staff A | Reported unawareness of resident's note about wanting to give up | |
| Social services staff Q | Reported lack of knowledge of resident's note about wanting to give up | |
| Administrative nursing staff B | Reported unawareness of resident's note and inability to locate 3 day voiding pattern | |
| Licensed nursing staff C | Reported night charge nurse notified about resident's note but did not notify physician | |
| Licensed nursing staff G | Reported knowledge of resident's note but had not notified physician | |
| Direct care staff I | Reported resident's assistance needs and toileting behavior | |
| Direct care staff K | Reported resident's toileting and hygiene assistance needs | |
| Licensed nursing staff U | Conducted blood sugar monitoring for resident #6 | |
| Direct care nursing staff H | Administered medications incorrectly to resident #20 | |
| Administrative nursing staff B | Acknowledged medication errors and lab monitoring issues | |
| Physician staff T | Ordered vitamin K and lab rechecks for resident #15 | |
| Physician staff S | Ordered lab re-draw for resident #15 |
Inspection Report
Plan of Correction
Deficiencies: 2
N011003 POC QBVO11
Visit Reason
This document is a Plan of Correction submitted by Gran Villas Columbus in response to deficiencies cited in the related deficiency report (2567).
Findings
The facility plans to adjust its Quality Assurance Committee efforts to maintain compliance, review and update negotiated service agreements for residents, and implement a blood sugar log book protocol to ensure proper monitoring and documentation of hypoglycemic interventions.
Deficiencies (2)
| Description |
|---|
| Negotiated service agreements for residents #1 and #3 lacked provider type of service and description of leg wraps order. |
| Staff were not adequately following the hypoglycemic protocol for resident #1, requiring in-service training and implementation of a blood sugar log book. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Administrator | Submitted the Plan of Correction |
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