Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Columbus Health And Rehab during CMS and state inspections, most recent first.
Cold Meal Temperatures: Residents reported that hot meals were arriving cold or undesirable, including cold oatmeal, cold room trays, and soggy biscuits. A surveyor’s test tray confirmed low temperatures for biscuits and gravy and scrambled eggs, and the DM acknowledged those temperatures were not desirable. The NHA stated the facility had a meal-temperature improvement plan, but staff were not following it and were placing trays for all hallways on one insulated cart.
Unsafe food storage and preparation practices were observed in the kitchen and freezer. Surveyors found dust on sprinkler heads above the food prep area, frozen drips and ice buildup in the walk-in freezer on unsealed food boxes, a staff member with a full goatee plating food without a beard restraint, and 3 dented cans in dry storage. The DM and NHA gave conflicting statements about cleaning, freezer protection, beard restraints, and dented cans.
Failure to Process Resident Grievances: A resident voiced repeated concerns about hot food being served at an undesirable temperature, and staff acknowledged they were not using the grievance process to document, track, or trend those complaints. Another cognitively intact resident with mobility-related diagnoses reported long waits for bathroom assistance and being left without help, but survey review found no grievance logged. Staff, including CNA, RN, DON, and NHA, stated the concerns should have been handled as grievances, yet they were not.
Medication pass observation and record review showed an excessive med error rate, with late administration of scheduled meds for three residents and one wrong med/dose error for another resident. Orders for 8:00 AM, 7:30 AM, and 7:00 AM meds were given outside the expected time window, and the DON and RN both agreed the late doses and the magnesium discrepancy were medication errors.
A facility failed to follow its abuse prevention and employee screening policy for a newly hired cook. The cook’s BID showed prior residence in Iowa and [NAME] Virginia, but the required background checks for those states were not in the file. During interview, the NHA confirmed the checks had been missed and should have been completed.
Failure to Report Alleged Neglect: A resident with cervical disc disorder with myelopathy, muscle weakness, lack of coordination, and a BIMS of 15 reported that a CNA did not return to change him/her during the night. CNA, LPN, RN, DON, and NHA interviews showed the concern was discussed among staff, but the alleged neglect was not immediately reported to the administrator and the SA as required by the facility’s abuse allegation policy.
Failure to Investigate Alleged Neglect: A cognitively intact resident with significant mobility-related diagnoses reported that a CNA had not changed or cared for him/her all night. Staff gave mixed accounts of the concern, but the DON and RN were not aware of any report, and no investigation was completed despite the facility’s abuse prevention policy requiring prompt investigation of alleged neglect.
A resident with dementia and a history of wandering/exit seeking was repeatedly assessed as low risk despite documented confusion, restlessness, and attempts to leave through exit doors. The care plan identified elopement risk and increased supervision, but interdisciplinary interventions such as reassurance and redirection were not added to the plan. The resident was later found outside ambulating independently after an alarm sounded, and records showed ongoing inaccurate elopement risk assessments and inconsistent supervision.
A resident at high risk for pressure ulcers due to immobility and multiple fractures developed two stage three and one unstageable pressure injuries. The facility failed to implement timely interventions, conduct regular assessments, and communicate effectively with the resident's physician. Inconsistent documentation and a reactive approach to pressure injury prevention contributed to the immediate jeopardy finding.
The facility was cited for deficiencies in food storage and labeling, affecting all 38 residents. Spoiled food items were found in the kitchen, and scoops were improperly stored in containers, risking cross-contamination. Additionally, nutritional supplements lacked use-by dates, making it impossible for staff to determine their expiration. The Dietary Manager and nursing staff acknowledged these issues.
The facility's assessment lacked essential details such as resident capacity, care requirements, and staff competencies. The assessment did not include benchmarks for resident conditions, therapies, or equipment needs. The NHA could not provide additional documentation to address these deficiencies.
The facility failed to maintain an effective infection control program, with deficiencies in water heater temperature monitoring and outdated pneumococcal vaccine policies. CNAs did not adhere to proper hand hygiene and glove-changing protocols during perineal care, risking resident safety.
A resident experienced excessive coughing leading to vomiting and a significant weight increase, indicating potential worsening of respiratory symptoms. Despite facility policy requiring immediate physician notification for such acute changes, the on-call physician was not contacted promptly. Instead, a message was left, and a fax was sent without immediate follow-up. Interviews with staff revealed inconsistencies in understanding the policy for immediate notification.
A facility failed to implement a toileting plan for a resident who was assessed as a candidate for retraining to maintain continence. Despite the resident's cognitive intactness and partial assistance needs, the facility did not attempt a toileting program, contrary to their policy. Interviews revealed a lack of clarity in responsibility for implementing and documenting bladder and bowel programs.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident receiving hospice care. There was no designated staff member to coordinate the plan of care, leading to outdated hospice documentation and a lack of alignment between the facility's care plan and the hospice care plan. Interviews with staff revealed that communication with hospice was handled individually by nurses, and the hospice binder was not consistently updated, resulting in a deficiency.
A resident with a wound vac experienced a deficiency in care when the LTC facility failed to have physician orders or a comprehensive care plan for the device. The wound vac ceased functioning, and staff were unable to obtain new orders, leading to the resident's unnecessary transfer to the ER. Interviews revealed a lack of recent training and inconsistent experience with wound vacs among staff.
A facility failed to ensure proper PICC line flushing protocol was followed, as a nurse did not aspirate for blood return before administering medication to a resident. The resident, with multiple health conditions, did not receive care in line with the facility's policy, which requires checking for blood return to ensure catheter patency. Interviews revealed inconsistencies in staff training and understanding of the protocol.
Cold Meal Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and at a safe, appetizing temperature for residents on all 3 units. Multiple residents, including R10, R23, R49, R1, R12, R18, R7, R30, R39, R2, R42, and R17, reported that hot foods were being served cold or at undesirable temperatures. Residents stated that meal trays delivered to their rooms were cold by the time they arrived, oatmeal was not warm, and biscuits were soggy. During the resident council meeting, several residents voiced repeated concerns that hot foods were being served at cold temperatures and that they had complained to staff many times about the issue. Surveyor observation and testing confirmed the concern. A test tray showed biscuits and gravy at 98 degrees and scrambled eggs at 96 degrees, both described as cool to the touch, while hot cereal measured 132 degrees. The dietary manager stated that 96 and 98 degrees were not desirable temperatures for hot food and acknowledged awareness of concerns about cold food. The dietary manager also stated that meals were cooling because all three hallways were being placed on one insulated cart and passed out from there, rather than serving one hallway at a time as intended. The nursing home administrator stated the facility had a Project Improvement Plan for meal temperatures, but kitchen staff failed to follow it and returned to placing all room trays in one insulated cart.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, and distribution. During observation of the main kitchen, surveyors saw 3 sprinkler heads and the surrounding ceiling covered in a thin layer of dust directly above the food preparation area. The Dietary Manager and another staff member were unsure who was responsible for cleaning those areas, and the Dietary Manager stated there was potential for dust to dislodge and fall into food being prepared underneath them. The Nursing Home Administrator later indicated maintenance staff should be cleaning those areas regularly. Surveyors also observed frozen drips hanging from the ceiling and sprinkler heads in the walk-in freezer, with ice buildup on and inside boxes of food that were no longer sealed by the manufacturer, including biscuit dough, vegetables, pork fritters, and beef patties. In addition, a staff member with a full goatee was observed plating residents' food on 2 days without a beard restraint, despite facility policy requiring beard restraints when working with food. Surveyors also found 3 dented cans in dry storage, and the Dietary Manager stated he would use a dented can if the dent was not on the seam, while the Nursing Home Administrator stated staff should not use dented cans at all.
Failure to Process Resident Grievances
Penalty
Summary
The facility did not ensure prompt resolution of resident grievances for multiple residents who voiced concerns to staff, including concerns about hot food being served at a cool or undesirable temperature and concerns about delayed or missed assistance with care. The facility policy required grievances or complaints to be investigated by the Grievance Official, reported in writing to the Administrator within 5 working days, and documented on a grievance log maintained for review by the Quality Assurance and Assessment Committee. However, staff members acknowledged that resident concerns were not being entered into the grievance process, tracked, or trended. Several staff members stated that residents R2, R7, R42, and R30 frequently complained about receiving hot food at a cold or undesirable temperature, but CNA P, CNA O, and CNA G said they did not complete grievance forms or report those concerns to the Grievance Official. The Activity Director stated that R7 complained almost daily that hot meals were served at a cooler and undesirable temperature, but those concerns were not recorded on grievance forms. The Dietary Manager also stated he was aware of resident concerns related to cold food and that staff should have been using grievance forms so he could see which halls, meals, and frequencies were involved. R30 stated she no longer went to staff with concerns because they did not do anything about them. R17, who had diagnoses including cervical disc disorder with myelopathy, muscle weakness, lack of coordination, and need for assistance with personal care, had a BIMS score of 15 indicating cognitive intactness. R17 reported waiting a long time for bathroom assistance and being left waiting after staff said they would get help. Surveyor review found no grievance in the facility log for R17’s concern. Multiple staff members described the incident, including that R17 was upset because staff stopped in the room, said they would get help, but did not assist. RN H stated the concern should have started the grievance process and that the resident should have been spoken with, while the DON and NHA both stated they would have expected to be notified and for the concern to be followed through as a grievance.
Medication pass errors exceeded allowable rate
Penalty
Summary
The facility did not ensure that its medication error rate remained below 5 percent. During a medication pass observation and record review, surveyors identified 8 errors out of 29 opportunities, affecting 3 of 4 residents observed, for an error rate of 27.59%. The errors included late administration of scheduled medications for three residents and one instance of the wrong medication and dose being given. For one resident with hypertension and severe cognitive impairment, lisinopril and hydralazine were ordered for 8:00 AM but were administered at 9:15 AM. For another resident with constipation and pain, acetaminophen, senna, and gabapentin were ordered for 7:30 AM or 7:00 AM but were administered at 8:58 AM and 8:59 AM. The facility’s DON and RN both stated that medications ordered for a specific time were expected to be given within the established time window, and both agreed the late administrations were medication errors. For a third resident with hypertension, history of venous thrombosis and embolism, and chronic pain syndrome, carbidopa-levodopa, dabigatran etexilate, metoprolol, and oxybutynin were ordered for 8:00 AM but were administered between 9:22 AM and 9:33 AM. In addition, magnesium gluconate 500 mg was ordered, but magnesium 200 mg was administered instead. The DON identified the wrong medication and dose as a medication error, and the RN verified that the magnesium given did not match the order.
Missing Background Checks for New Cook
Penalty
Summary
The facility did not ensure written policies and procedures were developed and implemented to prevent abuse, neglect, exploitation, and misappropriation of resident property for 1 of 8 staff reviewed for background checks. CK D, a cook hired by the facility, completed a Background Information Disclosure form that showed he had lived in Iowa and [NAME] Virginia in the last three years, but the facility did not complete background checks for either location. The facility policy for abuse prevention and screening of employees stated that background checks are completed per state guidelines and that pre-employment screening includes employment history, information from former employers as available, and documentation of status and disciplinary actions from licensing or registration boards or registries. During interview, the Nursing Home Administrator reviewed CK D’s file, could not find background checks for Iowa or [NAME] Virginia, and stated the checks had been missed and should have been completed. The administrator also stated the background checks had been filed and were pending at the time of the interview.
Failure to Report Alleged Neglect
Penalty
Summary
The facility did not ensure that an alleged violation involving neglect was immediately reported to the administrator and to the State Survey Agency in accordance with its abuse allegation reporting policy. The policy stated that all suspected violations and substantiated incidents of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation, must be immediately reported to appropriate state agencies and other required entities. The deficiency involved R17, who was admitted with cervical disc disorder with myelopathy, muscle weakness, lack of coordination, and a need for assistance with personal care. R17’s MDS dated 2/18/26 showed a BIMS score of 15, indicating cognitive intactness. During the survey, CNA G stated that a couple of weeks earlier R17 said he/she had not been changed all night and that this was reported to DON B and RN H. LPN I stated that when a resident says no one has helped them all night, staff should assess the situation, talk to the resident, and speak with DON B; regarding R17, LPN I said the resident’s statement sounded like a refusal and that the concern was handled after being shared with the nurse. RN H stated that if a CNA reports a resident concern, the DON and NHA should be called and the grievance process started, but RN H did not know of R17’s concern. R17 told the surveyor that the CNA on the 10:00 PM to 6:00 AM shift came in around 11:00 PM, asked if R17 was dry, and then did not return until about 5:00 AM, even though R17 needed to be changed a couple of times during the night. DON B stated she was not aware of the report, and NHA A stated the concern should have been self-reported as an allegation of neglect but had not been reported until the surveyor’s interview.
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility did not investigate an alleged incident of neglect involving a resident who was cognitively intact and had diagnoses including cervical disc disorder with myelopathy, muscle weakness, lack of coordination, and need for assistance with personal care. The resident reported that a CNA had not changed or cared for him/her all night. The facility’s Abuse Prevention Program required reports of resident abuse, neglect, mistreatment, and injuries of unknown source to be promptly and thoroughly investigated by management, with an appointed manager to investigate the allegation. During interviews, the CNA stated the resident had said a couple of weeks earlier that he/she had not been changed all night and that this was told to the DON and an RN. An LPN stated the resident’s concern sounded like a refusal and believed it had been handled after being shared with nursing staff. The RN stated she was not aware of the concern, and the DON stated she was not aware the allegation had been reported. The NHA stated the concern should have been reported and investigated as an allegation of neglect, but no investigation had been completed at the time of survey.
Inaccurate elopement assessment and incomplete care planning for a resident with wandering behaviors
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with dementia and a history of wandering and exit seeking. The resident was admitted with diagnoses including dementia and had a hospital discharge note stating she had been brought to the emergency room after increasing confusion and wandering outside of her house. The facility’s initial elopement risk assessment scored the resident as low risk, even though the record included forgetfulness, dementia, and a history of wandering. The assessment also did not consistently reflect the resident’s cognitive impairment or exit-seeking history. The resident’s comprehensive care plan identified a potential for elopement or wandering due to poor safety awareness, history of wandering, and cognitive deficits, and included interventions such as increasing supervision during periods of unsafe wandering. An interdisciplinary team note later documented exit-seeking behaviors in the evening, the resident’s belief that she needed to go home, and use of a wanderguard with staff checking placement and function each shift. The team also documented reassurance and redirection interventions, but those interventions were not added to the comprehensive care plan. Subsequent elopement risk assessments remained incomplete or inaccurate, omitting behaviors such as exit seeking, staying near exit doors, sundowning, and lack of safety awareness. The resident was later found outside ambulating independently after an alarm sounded at a back door, with staff assisting her back inside and into a wheelchair. Another note documented that she had attempted to elope through a side door, was roaming the halls, and staff were using 30-minute checks. An interdisciplinary team note described the resident as more confused after supper and noted she was ambulating through emergency exit doors after leaving her wheelchair near the door. The record also showed later episodes of restlessness, agitation, wandering, and repeated attempts to exit through doors, while the facility’s assessments continued to understate the resident’s elopement risk and did not accurately reflect her behaviors.
Failure to Prevent Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident identified as R30, who was at risk due to immobility and multiple fractures. The facility did not implement aggressive pressure injury interventions, failed to complete weekly assessments as per standard practice, and did not provide risk and benefits information despite knowing that R30 refused repositioning. As a result, R30 developed two stage three and one unstageable facility-acquired pressure injuries. R30 was admitted with a history of wedge compression fracture, Type 2 Diabetes, and muscle weakness, requiring substantial assistance with mobility. Despite being at risk for pressure injuries, the facility did not conduct timely assessments or implement necessary interventions such as air mattresses proactively. The facility's documentation was inconsistent, with gaps in wound assessments and measurements, and there was a lack of communication with R30's physician regarding the open areas identified upon admission. The facility's inaction led to the deterioration of R30's condition, with wounds progressing from MASD to stage three pressure injuries. The facility's failure to document repositioning efforts and the lack of a proactive approach to pressure injury prevention contributed to the immediate jeopardy finding. The facility's practice of using air mattresses reactively rather than proactively, despite R30's high risk, further exacerbated the situation.
Removal Plan
- Skin Assessment completed for each resident
- Braden Assessment completed for each resident
- Medical Director on site completed wound rounds assessment with DON, determined etiology, and validated appropriate treatment in place for R1 and all residents with wounds.
- Residents who scored <15 on Braden assessments have had care plans reviewed and updated with appropriate interventions based on areas of concern identified on Braden Assessment
- Educated Nursing Staff (Licensed and CNA) on pressure injuries - including risks, treatment guidelines, interventions & care strategies, wound care guidelines, and nutritional choices and support, educated on documentation of risk/benefit conversations in Refusal of Care progress note
- F686 - Review of F686 Pressure Injury Treatment Guidelines completed by Medical Director
- Review of Policy Pressure injury/skin breakdown - clinical guidelines reviewed by Medical Director
- Review of F686 Pressure Injury Risk Assessment Guidelines by Medical Director
- Initiation and education of Progress note specific to Refusals of Care and Risk/Benefits discussion to be used as documentation template for residents who refuse skin interventions
- F686 - Medical Director and/or Wound NP to review wound assessments weekly with facility nursing team either bedside at the facility or remotely to ensure thorough and accurate assessments, treatments remain appropriate, and standards of practice are maintained. Weekly reviews to continue unless concerns are noted during reviews. After the Provider oversight DON/Designee will audit 4 wound assessments & care plans weekly then 2 wound assessments weekly. Audit result will be reviewed with the Medical Director during QAPI. Audits will be discontinued based on QAPI committee recommendations.
- Ad hoc QAPI held with Medical Director, Acting Administrator, DON, and Governing Body. Action plans reviewed, discussed and agreed upon.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility was found to have deficiencies in food storage, preparation, and distribution, which could potentially affect all 38 residents. During an observation in the facility kitchen, a surveyor, along with the Dietary Manager (DM C), discovered spoiled food items, including a bag of fresh parsley and a bag of lettuce, both of which were visibly brown, slimy, and discolored. The parsley had a received date of 1/21/25, and the lettuce had a received date of 2/11/25. DM C acknowledged that these items should be discarded. Additionally, scoops were found inside containers of flour, brown sugar, and sugar, which DM C admitted could lead to cross-contamination. Further observations revealed that four Sysco Imperial Strawberry Shakes, a type of nutritional supplement, were stored in the medication room refrigerator without use-by dates. When questioned, RN E was unable to determine the expiration or disposal date for these shakes due to the lack of labels. The Nursing Home Administrator (NHA A) and Director of Nursing (DON B) confirmed that without labels, staff would not be able to accurately determine when the shakes should be used or disposed of, and they agreed that there should be use-by dates on such supplements.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all necessary details to provide adequate care and services to its residents. The assessment lacked critical information such as the facility's resident capacity, the care required by the resident population considering their diseases, conditions, and disabilities, and the staff competencies needed to provide the required level of care. Additionally, the assessment did not address the physical environment, equipment, and services necessary for the resident population, nor did it consider any ethnic, cultural, or religious factors that might affect care. The facility's policy on conducting a facility-wide assessment was not fully implemented. The assessment document reviewed by the surveyor was missing benchmarks for various categories, such as the number of residents the facility could accept with different conditions and therapies. The staffing section was marked as evaluated without providing specific information on staffing needs or competencies. Similarly, the sections on physical environment, technology, and equipment were marked as evaluated without listing the quantity or benchmarks for these resources. When asked for additional documentation, the Nursing Home Administrator (NHA) was unable to provide any further information beyond what was already reviewed. The surveyor noted that the required information, such as specific numbers of residents that could be accepted and the necessary equipment and staffing, was not present in the documentation. Another surveyor confirmed the absence of this information, indicating that the facility did not conduct a complete assessment to determine the resources necessary for resident care.
Infection Control Deficiencies in Water Management and Perineal Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not monitor the temperature of three out of five water heaters as part of their Water Management Program, which is crucial for preventing the growth of Legionella bacteria. The maintenance staff was unable to accurately state the required water temperature to prevent Legionella, indicating a lack of proper training or understanding of the facility's water management protocols. Additionally, the facility's policy and procedure for the Pneumococcal Vaccine was found to be outdated. The Director of Nursing/Infection Preventionist was not aware of the latest guidance regarding pneumococcal vaccines, which could lead to residents not receiving the appropriate vaccinations as per current recommendations. This oversight in updating the vaccine policy could potentially affect the health and safety of the residents. Multiple breaches in infection control practices were observed during the provision of perineal care to residents. Certified Nursing Assistants (CNAs) failed to perform hand hygiene and change gloves appropriately after contact with bodily fluids, before touching resident items, or when moving from dirty to clean tasks. These lapses in infection control were observed with several residents, indicating a systemic issue with staff adherence to infection control protocols. The Director of Nursing confirmed that the expected hand hygiene practices were not followed, further highlighting the deficiency in the facility's infection control program.
Failure to Immediately Notify Physician of Resident's Acute Condition
Penalty
Summary
The facility failed to immediately consult with a physician when there was a need to alter treatment for a resident, identified as R8, who was reviewed for physician notification. R8 experienced an episode of excessive coughing that led to vomiting in October 2024. Despite the facility's policy requiring immediate physician notification for acute changes in condition, the on-call physician was not contacted to allow for potential treatment alterations. Instead, a message was left for the primary care provider, and a fax was sent without immediate follow-up, which did not meet the standard of immediate notification. Additionally, in February 2025, R8 experienced a significant weight increase of four pounds in one day, which was a notable change given R8's medical conditions, including Acute on Chronic Systolic Heart Failure. This weight change, coupled with labored breathing and low oxygen saturation, indicated a potential worsening of respiratory symptoms. However, there was no clear documentation that the physician was notified immediately, as required by the facility's standard of practice and regulations. Interviews with facility staff, including an LPN and the Director of Nursing, revealed inconsistencies in understanding and implementing the facility's policy for immediate physician notification. The LPN indicated that she would notify a physician within a couple of hours after assessing the resident, while the Director of Nursing stated that immediate notification should occur as soon as practicable. Both staff members acknowledged that the situations involving R8 warranted immediate physician notification, yet the actions taken did not align with this understanding.
Failure to Implement Toileting Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was continent of bladder and bowel upon admission, received the necessary services and assistance to maintain continence. The resident, identified as R25, was assessed and determined to be a candidate for retraining, yet the facility did not develop a toileting plan for them. The facility's policy on urinary incontinence required an initial assessment to identify individuals with impaired urinary continence and to provide interventions such as scheduled toileting to improve continence status. However, R25's care plan did not include any habit training or scheduled toileting program, despite the resident's evaluation indicating a potential for continence improvement through such a program. R25 was admitted with multiple diagnoses, including polyosteoarthritis, atherosclerotic heart disease, type 2 diabetes, hypertension, and muscle weakness. The resident was cognitively intact and required partial/moderate assistance for toilet transfers and walking. Despite being frequently incontinent, the facility did not attempt a toileting program since admission. Interviews with the RN and DON revealed a lack of clarity and responsibility regarding the implementation and documentation of bladder and bowel programs. The DON acknowledged that if the facility planned to conduct interventions, they should have been executed and documented, which was not done in this case.
Deficiency in Hospice Collaboration and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with a hospice provider for a resident receiving hospice care. The facility did not have a designated staff member to coordinate the plan of care with the hospice provider, which led to a lack of updated hospice documentation being available to facility staff. The hospice plan of care and visit notes for the resident were not readily accessible, and the most recent documents available were outdated, with no current plan of care or visit notes from 2025. This lack of documentation hindered the facility's ability to ensure that the facility's care plan and the hospice care plan were aligned. Interviews with facility staff, including LPNs and the DON, revealed that there was no specific contact person for hospice coordination, and communication with hospice was handled individually by nurses. The hospice binder, which was supposed to contain relevant information, was not consistently updated or maintained, leading to gaps in the continuity of care. The facility's policy required a designated staff member to ensure the availability of hospice documents and coordinate care, but this was not implemented, resulting in a deficiency in hospice collaboration and communication processes.
Deficiency in Wound Vac Management Leads to Unnecessary ER Visit
Penalty
Summary
The facility failed to ensure that services met professional standards of quality for a resident who was admitted with a wound vac. The resident, who was cognitively intact, had a history of sepsis due to a surgical site infection and was at risk for skin breakdown due to multiple factors including diabetes and limited mobility. Despite these risks, the facility did not have physician orders for the wound vac in the resident's medical record, nor did they have a policy regarding wound vacs. The resident's wound vac ceased to function as it reached the end of its 14-day working life, and the facility staff were unable to obtain new orders for its management. The staff attempted to contact various physicians, including the on-call neurosurgeon and infectious disease specialists, but were directed to send the resident to the emergency room for further evaluation. This lack of coordination and absence of a backup plan in the care plan or physician orders led to the resident being unnecessarily transferred to the ER, causing him significant stress and anxiety. Interviews with facility staff revealed a lack of recent training on wound vacs and inconsistent experience with their use. The Director of Nursing acknowledged that the care plan did not include specific instructions for managing the wound vac or who to contact in case of malfunction. The facility's failure to have a comprehensive care plan and physician orders for the wound vac contributed to the deficiency, resulting in the resident's distress and unnecessary ER visit.
Failure to Follow PICC Line Flushing Protocol
Penalty
Summary
The facility failed to ensure that nursing staff followed professional standards of practice when flushing a peripherally inserted central catheter (PICC) for a resident. The deficiency was observed when RN/MDS L did not aspirate to check for blood return before flushing the PICC line of a resident, which is a necessary step to verify catheter patency according to the facility's policy. The policy requires that blood return be checked to ensure the catheter is patent before administering medication, but this step was omitted during the procedure. The resident involved, identified as R237, was a recent short-term admission with diagnoses including sepsis due to methicillin-resistant Staphylococcus aureus, infection following a surgical procedure, type 2 diabetes mellitus, and morbid obesity. During the observation, RN/MDS L performed the PICC line medication initiation without aspirating for blood return, contrary to the facility's policy and procedure. This oversight was confirmed during an interview with RN/MDS L, who stated that she was not taught to aspirate for blood return with a PICC line, indicating a gap in training and competency verification. Further interviews with other nursing staff, including RN M and RN D, revealed inconsistencies in the understanding and execution of the PICC line flushing protocol. RN M was aware of the need to aspirate for blood return, having been taught this practice in a hospital setting, while RN D did not perform this step. The Director of Nursing/Infection Preventionist (DON/IP B) also did not expect blood aspiration prior to medication administration, highlighting a lack of standardized training and competency checks for PICC line care within the facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaver Dam Health Care Center | 12.7 mi | ★★★★★ | 23 | 2 |
| Hillside Manor | 12.9 mi | ★★★★★ | 9 | 0 |
| Randolph Health Services | 13.9 mi | ★★★★★ | 11 | 0 |
| Sun Prairie Senior Living | 14 mi | ★★★★★ | 23 | 0 |
| Avina Of Sun Prairie | 15 mi | ★★★★★ | 10 | 0 |
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