Inspection Reports for
Medicalodges Columbus
101 LEE AVENUE, PO BOX 351, COLUMBUS, KS, 66725-351
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
78% occupied
Based on a January 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
A second revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-02-21.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2019-03-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
A second revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-02-21.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-03-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 15
Date: 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 (Event ID 2K3111). It outlines corrective actions to address identified issues and ensure compliance with regulatory requirements.
Findings
The Plan of Correction details multiple corrective actions including removal and replacement of contaminated or damaged resident items, environmental and maintenance repairs, staff education on infection control and care planning, medication management improvements, and ongoing monitoring and auditing to maintain compliance.
Deficiencies (15)
F584-E: Resident bathrooms had improperly stored and unlabeled hairbrushes, denture cups without lids, and dirty fall mats which were removed and replaced. Cracked linoleum and bent window blinds were scheduled for repair or replacement.
F655-D: Care plans for residents #30 and #134 were reviewed and updated; nursing staff educated on baseline care plan development within 48 hours of admission.
F657-D: Resident #28's care plan was revised to prevent weight loss; nursing and dietary staff educated on care plan review and updates.
F688-D: Resident #21 to receive therapy screening for restorative program needs; staff educated on restorative nursing policy and program implementation.
F689-E: Chemical hazards accessible to residents in community shower rooms were removed; staff received training on chemical and hazard storage; monitoring established.
F692-G: Resident #26 had medication review and restorative dining program initiated; staff educated on weight management and meal service protocols.
F695-D: Resident #134's care plan updated for respiratory needs; physician orders clarified; staff educated on respiratory equipment infection control.
F725-F: Facility staff to receive in-service training and ensure direct care schedule assignments are complete; Director of Nursing to oversee scheduling.
F730-E: Direct care staff employed over a year to complete at least 12 hours of education; skills fair to facilitate training coordinated by Director of Nursing and corporate consultants.
F757-D: Resident #21 PRN Tramadol discontinued; PRN medications reviewed for non-use over 30 days with physician follow-up; staff educated on PRN medication review procedures.
F758-D: Psychotropic medication assessments completed for residents #19 and #21; staff educated on assessment completion; monitoring established.
F761-E: Insulin pens labeled with pharmacy labels including dosage and date opened; expired medications removed; staff educated on medication storage and cart security.
F812-F: Opened kitchen items exceeding 72 hours storage removed; damaged kitchen tools replaced; staff trained on disposal and replacement procedures.
F880-E: Resident bath basins, bed pans, and urine graduates replaced with new items and appropriate storage bags; infection control education provided; monitoring established.
F921-E: Resident positioning devices and items stored on floor removed; department managers assigned to monitor storage; staff trained on proper storage.
Report Facts
Completion date: Feb 9, 2019
Education completion date: Jan 31, 2019
Medication cart audit frequency: 4
Daily monitoring frequency: 5
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 15
Date: Jan 10, 2019
Visit Reason
The visit was a Health Resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and comfortable environment, baseline care plan development and revision, range of motion maintenance, accident hazard prevention, nutrition and hydration maintenance, respiratory care, sufficient nursing staff, nurse aide training, medication management, food safety, infection prevention and control, and environmental safety.
Deficiencies (15)
F584: The facility failed to maintain a sanitary, orderly, and comfortable interior for 5 of 28 rooms and a shower room, including torn fall mats, dirty linens, and unclean personal items stored improperly.
F655: The facility failed to develop and implement baseline care plans within 48 hours of admission for residents, including failure to provide written summaries to residents or representatives.
F657: The facility failed to review and revise the care plan for a resident to prevent significant weight loss, lacking interventions such as high calorie snacks and fortified foods.
F688: The facility failed to provide appropriate treatment and services to maintain range of motion for a resident with a left hand contracture, including lack of restorative services and splint use.
F689: The facility failed to keep hazardous chemicals locked and out of reach of confused residents, with chemicals stored in unlocked cabinets and on shower room floors.
F692: The facility failed to ensure a resident maintained adequate nutrition, including failure to cue and assist with meals, maintain food temperature, and offer alternatives, resulting in significant weight loss.
F695: The facility failed to provide necessary respiratory care and services, including failure to clarify physician orders for inhalation treatments and improper cleaning of inhalation equipment.
F725: The facility failed to have sufficient nursing staff to provide care based on residents' individualized needs, resulting in delayed call light responses, missed cares, and unsafe transfers.
F730: The facility failed to ensure direct care staff employed over a year completed at least 12 hours of in-service education.
F757: The facility failed to monitor unused PRN medications, resulting in continued storage of unused Tramadol for a resident without physician review.
F758: The facility failed to complete psychotropic medication assessments (AIMS or DISCUS) for residents started on antipsychotic medications to monitor for side effects and prevent unnecessary use.
F761: The facility failed to properly label insulin pens with dosage and open dates, failed to remove expired medications, and failed to secure medication carts during medication passes.
F812: The facility failed to store and prepare food under sanitary conditions, including use of expired food, undated leftovers, damaged cutting boards and skillets.
F880: The facility failed to provide proper infection control practices, including dirty linens on the floor, improper storage of bedpans, urine containers, urinary drainage bags, and trash cans placed on commodes and bedside tables.
F921: The facility failed to maintain a safe, sanitary, and comfortable environment, with resident positioning devices and medical supplies stored directly on floors in supply and restorative closets.
Report Facts
Resident census: 35
Weight loss: 15
Hours of training: 6.25
Hours of training: 7.25
Hours of training: 8.25
Hours of training: 8
Medication expiration: 12
Weight loss percent: 10.49
Weight loss percent: 14.48
Weight loss percent: 5.03
Weight loss percent: 1.3
Weight loss percent: 10.49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Licensed Nursing Staff | Named in medication cart and expired medication findings |
| Staff B | Administrative Nursing Staff | Named in baseline care plan and respiratory care findings |
| Staff F | Direct Care Staff | Named in restorative services and range of motion findings |
| Staff I | Licensed Nursing Staff | Named in respiratory care and psychotropic medication findings |
| Staff J | Direct Care Staff | Named in range of motion and nutrition findings |
| Staff G | Direct Care Staff | Named in infection control and nutrition findings |
| Staff K | Direct Care Staff | Named in nutrition and staffing findings |
| Staff S | Licensed Nursing Staff | Named in medication cart and nutrition findings |
| Staff U | Direct Care Staff | Named in staffing findings |
| Staff AA | Direct Care Staff | Named in staffing findings |
| Staff C | Dietary Staff | Named in nutrition and food safety findings |
| Staff Q | Dietary Staff | Named in food safety findings |
| Staff X | Dietary Staff | Named in food safety findings |
| Staff L | Consultant Staff | Named in restorative services and staffing findings |
| Staff E | Social Service Staff | Named in baseline care plan findings |
| Staff W | Licensed Nursing Staff | Named in baseline care plan findings |
Inspection Report
Renewal
Census: 12
Deficiencies: 11
Date: Sep 25, 2018
Visit Reason
Licensure resurvey conducted over multiple days to assess compliance with state regulations for an assisted living or residential health care facility.
Findings
The facility was found deficient in multiple areas including failure to conduct timely and accurate functional capacity screenings, incomplete negotiated service agreements, inadequate medication management and labeling, lack of proper documentation of incidents and medication administration times, and insufficient disaster and emergency preparedness training and drills.
Deficiencies (11)
KAR 26-41-201(c) Functional Capacity Screen Reassessment was not conducted at least every 365 days for one resident.
KAR 26-41-201(d) Functional Capacity Screen was inaccurate for two residents regarding their abilities at the time of screening.
KAR 26-41-202(c) Initial negotiated service agreement was not developed at admission for one newly admitted resident.
KAR 26-41-204(a) Licensed nurse failed to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreement for two residents related to fall risk.
KAR 26-41-204(d) Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health care service plan for three residents.
KAR 26-41-205(a)(1) Licensed nurse failed to assess a resident's ability to safely self-administer medications before allowing self-administration.
KAR 26-41-205(g)(2) Prescription medication containers for two residents were not labeled with pharmacist-provided labels as required.
KAR 26-41-205(h)(4) Medications were available for administration past the manufacturer use-by date for two residents.
KAR 26-41-205(k)(4) Clinical records for three residents lacked documentation of the date and time medications were administered.
KAR 26-41-105(f)(11) Resident records for three residents lacked documentation of all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results.
KAR 26-41-104(d) Facility failed to provide quarterly emergency management plan reviews for staff and residents, failed to provide disaster preparedness training for two new employees, and failed to conduct an annual emergency drill including resident evacuation to a secure location.
Report Facts
Resident census: 12
Deficiencies cited: 11
Fall incidents: 3
Insulin pen expiration days: 28
Insulin pen use days: 47
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 1, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior deficiency report.
Findings
No deficiencies were cited in this Plan of Correction as indicated by the F0000 tag.
Deficiencies (1)
F0000 No deficiencies cited in this report.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 1, 2017
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 no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 10, 2016
Visit Reason
The licensure survey was conducted to assess compliance for the initial licensing of the facility Medicalodges Columbus.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 26, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior inspection report.
Findings
No deficiencies were cited in the related inspection report dated 04/26/2016.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 26, 2016
Visit Reason
The health survey was conducted 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: 2
Date: Mar 24, 2015
Visit Reason
This document is a Plan of Correction submitted by Gran Villas Columbus in response to deficiencies identified in a prior inspection report (Medicalodges Columbus ALF 031815).
Findings
The facility addressed issues related to negotiated service agreements and health care services standards of practice, including hypoglycemic protocol adherence and documentation improvements.
Deficiencies (2)
S3085 Negotiated Service Agreement: The facility reviewed and corrected negotiated service agreements for residents #1 and #3 to include provider type and specific orders. The Administrator will monitor monthly for ongoing compliance.
S3171 Health Care Services Standards of Practice: Staff were in-serviced on resident #1's hypoglycemic protocol, and a blood sugar log book was implemented to document interventions and monitoring. Daily monitoring and monthly reporting to the Quality Assurance Committee will continue.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Higgins | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 20, 2015
Visit Reason
This report documents a revisit inspection to verify correction of previously cited deficiencies at the facility.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 26-41-202 (a) and 26-41-204 (i) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-202 (a): Previously cited deficiency corrected as of 03/20/2015.
Regulation 26-41-204 (i): Previously cited deficiency corrected as of 03/20/2015.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Mar 20, 2015
Visit Reason
This report documents a revisit inspection to verify correction of previously reported deficiencies at the facility.
Findings
The revisit confirmed that the deficiencies identified in the prior survey were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-202 (a) deficiency was corrected by 03/20/2015.
Regulation 26-41-204 (i) deficiency was corrected by 03/20/2015.
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 2
Date: Mar 18, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to verify 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 by not following the hypoglycemia protocol for 48 episodes of low blood sugar readings.
Deficiencies (2)
26-41-202 (a) Negotiated Service Agreement: The facility failed to develop negotiated service agreements including service descriptions and provider identification for two residents, including wellness monitoring and leg wrap treatments.
26-41-204 (i) Health Care Services Standards of Practice: The facility failed to provide care according to acceptable standards and did not follow the hypoglycemia protocol for resident #1 with 48 low blood sugar episodes.
Report Facts
Resident census: 15
Low blood sugar episodes: 48
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 22, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Columbus to address deficiencies identified in a prior inspection.
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 ensure compliance and prevent unnecessary medication use.
Deficiencies (4)
F0000: The facility will adjust its Quality Assurance efforts to maintain substantial compliance with participation requirements and provide responses to the Quality Assurance Committee for review.
F280-D: The facility will implement care plan interventions and hold weekly weight meetings to monitor and address significant weight changes in residents.
F325-D: The facility will ensure interventions for residents with weight changes, hold weekly weight meetings, and monitor compliance through the Quality Assurance Committee.
F329-E: The facility will re-educate nursing and direct care staff on behavior monitoring protocols to ensure appropriate interventions and prevent unnecessary medication use, with monitoring by the Director of Nursing.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 22, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(i) and (l) have been corrected as of the revisit date.
Deficiencies (3)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies have been corrected as of 01/22/2015.
Regulation 483.25(i): Previously cited deficiency corrected as of 01/22/2015.
Regulation 483.25(l): Previously cited deficiency corrected as of 01/22/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 22, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously reported under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(i), 483.25(l) have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 8, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm but 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 is found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an "E" level deficiency pattern that constitutes no actual harm but has potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the survey findings and plan of correction. |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 3
Date: Jan 8, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies related to resident care and medication management.
Findings
The facility failed to revise the care plan for a resident with weight loss, failed to implement timely interventions to prevent continued weight loss, and failed to adequately monitor medications and behaviors for several residents, resulting in unnecessary medication use and lack of proper documentation.
Deficiencies (3)
F280: The facility failed to revise the care plan related to weight loss for one resident despite documented weight loss and physician instructions for careful observation.
F325: The facility failed to maintain nutritional status by not implementing timely and effective interventions to prevent continued weight loss for one resident.
F329: The facility failed to monitor medications and resident behaviors adequately, resulting in unnecessary medication use and lack of documentation of behavioral interventions for multiple residents.
Report Facts
Resident census: 38
Residents sampled: 15
Residents reviewed for nutrition/weight loss: 3
Residents reviewed for unnecessary medications: 5
Weight loss percentage: 5
Weight loss days documented: 4
Weight loss days documented: 2
Lorazepam PRN administrations: 10
Lorazepam PRN administrations: 4
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 10, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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 possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was found to have an 'F' level deficiency that was widespread with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jul 10, 2014
Provider agreement termination date: Oct 10, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 10, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied 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 possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
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 |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 21, 2013
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with ID prefix S0640 and regulation 28-39-158(g) was corrected as of 10/16/2013. No other deficiencies are listed as uncorrected.
Deficiencies (1)
Regulation 28-39-158(g) deficiency identified by prefix S0640 was corrected on 10/16/2013.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 21, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report documents that the previously identified deficiency with regulation 28-39-158(g) was corrected as of 2013-10-16. No other deficiencies are listed as outstanding.
Deficiencies (1)
Regulation 28-39-158(g) deficiency was corrected on 2013-10-16.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 21, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that previously cited deficiencies under regulations 483.25(c), 483.25(h), and 483.35(i) were corrected as of 10/16/2013.
Deficiencies (3)
Regulation 483.25(c) deficiency was corrected by 10/16/2013.
Regulation 483.25(h) deficiency was corrected by 10/16/2013.
Regulation 483.35(i) deficiency was corrected by 10/16/2013.
Report Facts
Correction completion date: Oct 16, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Gran Villas Columbus to address deficiencies identified in a prior inspection report (Medicalodges Columbus ALF 092413).
Findings
The facility identified issues related to sanitary conditions, specifically the cleanliness of the kitchen stove and overall kitchen area. Corrective actions include deep cleaning and routine maintenance schedules to ensure ongoing compliance.
Deficiencies (1)
S640 Sanitary Conditions: The facility's Maintenance Supervisor and Certified Dietary Manager will deep clean the stove and replace knobs and burners as needed. A deep cleaning of the kitchen was completed and added to a quarterly cleaning schedule monitored weekly.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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 improve quality assurance efforts to maintain compliance. Specific corrective actions include re-educating staff on pressure sore prevention, implementing fall risk identification measures, and enhancing kitchen sanitation procedures.
Deficiencies (3)
F314 Treatment/SVCS to Prevent/heal pressure sores: The facility will re-educate and in-service all direct care and licensed staff on recording abnormal skin areas and reporting to the charge nurse and Director of Nursing. This training will be part of new hire orientation and monitored weekly by the ID team and monthly by the Quality Assurance committee.
F323 Free of accident hazards/Supervision/Devices: The facility will tag wheelchairs of fall risk residents with colored tags and bell/alarm symbol stickers. Staff will be in-serviced on this system and compliance monitored by the Director of Nursing and weekly safety meetings.
F371 Food Procure,Store/Prepare/Serve-Sanitary: The Maintenance Supervisor and Dietary Manager will deep clean the stove and kitchen, replace knobs and burners as needed, and add deep cleaning to a quarterly schedule. Ongoing compliance will be monitored weekly and reported to the Quality Assurance committee.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 3
Date: Sep 24, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following previous deficiencies.
Findings
The facility failed to prevent and properly treat a pressure ulcer in one resident, did not provide adequate fall prevention interventions for another resident, and failed to maintain sanitary conditions in the kitchen food preparation areas.
Deficiencies (3)
F 314: The facility failed to identify, adequately assess, and provide timely treatment for a facility-acquired unstageable pressure ulcer on resident #51's outer right ankle.
F 323: The facility failed to provide planned interventions to ensure resident #53 remained free of falls, including failure to properly use alarms and supervision.
F 371: The facility failed to maintain clean food preparation areas, including ovens with burned substance buildup, a stained hand washing sink, and a grimy microwave top.
Report Facts
Census: 44
Residents sampled: 19
Residents with pressure ulcers: 3
Fall risk assessment score: 15
Fall risk assessment score: 22
Pressure ulcer size: 1.5
Inspection Report
Renewal
Census: 20
Deficiencies: 1
Date: Sep 24, 2013
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with regulatory requirements for facility licensure renewal.
Findings
The facility failed to maintain sanitary conditions in the kitchen, including accumulation of burned substances and grime on ovens and stove, an unclean hand washing sink, and a sticky layer of grime on the microwave, risking food borne illness to residents.
Deficiencies (1)
28-39-158(g) SANITARY CONDITIONS: The facility failed to ensure clean food preparation areas, including ovens with burned substance buildup, grime on stove knobs, an unclean hand washing sink, and a sticky microwave surface.
Report Facts
Census: 20
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 3, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 3, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey completed on 2012-06-11.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of the revisit date. The report documents the correction completion dates for each cited deficiency.
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jul 3, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Columbus to address 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 administration, and monitoring of drug regimens.
Deficiencies (8)
F0000: Medicalodges Columbus will adjust its Quality Assurance committee efforts to maintain substantial compliance with participation requirements.
F157-D: The facility will provide immediate notification of appropriate parties for changes in residents' mental condition and provide in-service training to licensed nursing staff.
F253-E: The facility will maintain a sanitary, orderly, and comfortable interior through housekeeping and maintenance services, including carpet removal and cleaning of beauty shop tools.
F272-D: Nursing personnel will reassess 3-day voiding patterns for specified residents and others not reassessed within 90 days, with staff training on this process.
F312-D: Personal hygiene needs of Resident #6 were addressed; staff will receive training on ADL care to ensure appropriate treatment for all residents.
F315-D: Staff will be trained on urinary incontinence, catheter care, and urinary tract infection to ensure proper treatment for Resident #14 and others.
F329-D: The consulting pharmacist will monitor drug regimens monthly to prevent unnecessary medications; staff will be trained on communication and notification procedures.
F332-D: Education and training on medication administration will be provided to licensed nursing personnel and certified medication aides to ensure medications are given as ordered.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 7
Date: Jun 11, 2012
Visit Reason
Re-survey of a health facility to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to notify a physician of a resident's mental health deterioration, maintain a clean environment, conduct comprehensive assessments for incontinence, provide adequate ADL care, monitor laboratory tests for Coumadin therapy, and ensure medication administration without errors.
Deficiencies (7)
F157: The facility failed to notify the physician when a resident demonstrated a deterioration in mental health and expressed suicidal ideation.
F253: The facility failed to maintain a clean and homelike environment, including unclean combs in the beauty shop and stained, discolored carpeting.
F272: The facility failed to conduct comprehensive assessments for incontinence, including a 3-day voiding pattern, for three residents to establish individualized toileting plans.
F312: The facility failed to provide adequate grooming and hygiene assistance to a dependent resident, evidenced by long facial hair, broken and dirty fingernails, and yellow mattering in the eyes.
F315: The facility failed to ensure a resident with urinary incontinence received timely toileting opportunities and proper hygiene to prevent urinary tract infections.
F329: The facility failed to monitor laboratory tests for Coumadin therapy timely, resulting in critical high PT/INR levels and bleeding complications.
F332: The facility had a medication error rate of 5.45%, including administration of medications at incorrect times and failure to rinse the resident's mouth after inhalation medication.
Report Facts
Resident census: 39
Residents selected for review: 21
Medication pass opportunities: 55
Medication errors: 3
Medication error rate: 5.45
PT lab result: 21.5
INR lab result: 2.8
PT lab result: 35.9
INR lab result: 6.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Direct care staff | Reported resident needed assistance with bathing, dressing, toileting, and was difficult to get to allow changing or bathing |
| Staff K | Direct care staff | Reported resident needed staff to keep clean and dry of urine and bowel movements |
| Staff B | Administrative nursing staff | Verified prior knowledge of physician absence and failure to obtain lab tests |
| Staff T | Physician staff | Ordered vitamin K and lab re-draw after critical PT/INR results |
| Staff C | Licensed nursing staff | Reported resident dressing shifted causing shearing and bleeding risk |
| Staff G | Licensed nursing staff | Reported hospital lab personnel did not communicate about lab draws |
| Staff H | Direct care nursing staff | Administered medications incorrectly during morning meal |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N011003 POC J1OG11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a healthcare facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan following a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N011003 POC LFR611
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
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