Colonial Manors of Columbus Community

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure accurate resident code status (resident decision to have cardiopulmonary resuscitation (CPR) performed or do not resuscitate (DNR) in the event of cardiac arrest) information recorded and readily available for 1 of 16 residents (Resident #24) reviewed for code status. The facility reported a census of 30 residents. The Minimum Data Set (MDS) assessment for Resident #17, dated [DATE], identified the resident had a diagnoses of cerebral vascular accident and dementia, and a Brief Interview for Mental Status score of 11 out of 15 (indicative of moderate mental impairment). [...]

Inspectors wroteBased on clinical record review, review of facility incident reports, review of facility policy, family member and staff interview, the facility failed to ensure staff followed their policy for reporting allegations of abuse for 1 of 1 sampled residents (Resident #17) reviewed with an allegation of abuse. The facility reported a census of 30 residents. Review of the Minimum Data Set (MDS) assessment for Resident #17, dated 6/9/25, identified the resident had a diagnosis of dementia. The assessment included a Staff Assessment for Mental Status which indicated Resident #17 had short term and long term memory problems. The Cognitive Skills for Daily Decision Making assessed the resident as Severely impaired (defined as never/rarely made decisions). [...]

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure admission Minimum Data Set (MDS) assessments completed timely for four of four residents reviewed for completion of comprehensive assessments (Resident #5, Resident #13, Resident #26, Resident #29). The facility reported a census of 28 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to update the Care Plan following initiation of anticoagulant medication, failed to ensure updated fall interventions were included following resident falls, failed to include a wound, and failed to address Clostridium Difficile for four of thirteen residents reviewed for Care Plan revision (Resident #6, Resident #15, Resident #20, Resident #27). The facility reported a census of 28 residents.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident's medications they took for 1 of 5 residents reviewed for unnecessary medications (Resident #5). The facility reported a census of 28 residents.

Inspectors wroteBased on the record review, staff interview, and the facility policy, the facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) with new mental health diagnoses and psychotropic medications added to the plan of care for 2 of 2 residents reviewed for PASRR (Resident #19 and Resident #20). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure diuretic medication was included in the comprehensive Care Plan for one of five residents reviewed for unnecessary medications (Resident #26). The facility reported a census of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure diuretic medication administered per physician order for one of two residents reviewed for edema (Resident #7). The facility reported a census of 28 residents.

Inspectors wroteBased on record review, resident interview, and the staff interviews, the facility failed to provide a shower twice a week for 1 of 1 residents reviewed for ADLs (Activities of Daily Living) (Resident #13). The facility reported a census of 28 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure daily weights obtained per Physician Order for two of two residents reviewed for edema (Resident #7, Resident #9), and failed to ensure timely, consistent follow up after documentation of no bowel movement (BM) for greater than three days for one of one resident reviewed for bowel and bladder (Resident #9), and failed to ensure thorough assessment completion for a resident's heel wound for one of two residents reviewed for wounds (Resident #20). The facility reported a census of 28 residents.

Inspectors wroteBased on record review, staff interview, and the facility policy, the facility failed to have the physician respond to the pharmacist GDR (Gradual Dosage Reduction) recommendation letter in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident #19). The facility reported a census of 28 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility QAPI (Quality Assurance and Performance Improvement) Plan, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last ten months. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure 4 of 5 residents were offered up to date pneumococcal (referring to pneumonia) vaccinations (Residents #4, #10, #15, #16). The facility reported a census of 24 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans were revised to include use of anticoagulant medications, updated interventions for falls, and use of opioid medication for two of twelve residents reviewed for Care Plans (Resident #10, Resident #17). The facility reported a census of 24 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out assessments and interventions when a resident did not have a bowel movement for multiple days for 1 of 2 residents reviewed on narcotic pain medications (Resident #10). The facility reported a census of 24 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to implement resident specific interventions for elopement and failed to ensure elopement alert devices were consistently checked for two of two residents reviewed for elopement (Resident #8, Resident #15). The facility reported a census of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary catheter tubing and catheter drainage bag remained off of the floor for one of one resident reviewed for catheters (Resident #4). The facility reported a census of 24 residents.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure timely follow up on medication regimen review recommendations for one of five residents reviewed for unnecessary medications (Resident #8). The facility reported a census of 24 residents.

Inspectors wroteBased on clinical record review, policy review, resident interview, and staff interview, the facility failed to provide routine dental services for 3 of 3 residents reviewed for the provision of dental services (Residents #10, #11, and #16). The facility reported a census of 24 residents.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure adherence to antibiotic stewardship practices prior to the administration of antibiotics for one of one resident reviewed for antibiotic stewardship (Resident #9). The facility reported a census of 24 residents.