Columbus Alzheimer's Care Ctr

Inspectors wroteBased on observations, staff interview, and review of facility policies, the facility failed to store food and wash dishes in a safe and sanitary manner. This had the potential to affect all 99 residents in the facility who ate food from the kitchen. The facility census was 99 residents.1. Observations in the dry storage room on 07/06/26 at 8:51 A.M. revealed individual servings of sweet and sour sauce were labeled as opened on 06/06/26 and use by 06/26/26. Observations in the walk-in refrigerator on 07/06/26 at 8:58 A.M. revealed the following concerns:-A tray of diced peppers labeled best by 06/30/26.-A 5 pound tub of sour cream, opened and partially full with no open date. -An opened, partially full, 25-pound tub of hard-boiled eggs with a delivery date of 06/11/26 and no open date. An interview with Dietary Director #240 on 07/06/26 at 9:10 A.M. confirmed the above findings. [...]

Inspectors wroteBased on record review, observation, interviews, and review of facility policy, the facility failed to properly store medication for Resident #82. This affected one resident (#82) and had the potential to affect 40 independently mobile residents on the memory care unit (#7, #11, #13, #17, #23, #27, #29, #33, #35, #37, #39, #42, #43, #44, #46, #48, #49, #50, #51, #53, #58, #60, #61, #62, #66, #67, #71, #73, #74, #75, #80, #82, #84, #85, #87, #89, #90, #93, #94, and #97). Additionally, the facility failed to ensure two out of three medication carts were maintained without loose medications. [...]

Inspectors wroteBased on review of resident medical records, review of the code status book, interviews, and review of facility policy, the facility failed to clearly identify code statuses. This affected two residents (#05 and #77) out of three residents reviewed for advanced directives. The facility census was 99 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure care plans were updated and accurate for residents. This affected three residents (#11, #16, and #97) out of 22 residents in the survey sample. The resident census was 99.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure physician ordered wound treatments were documented as completed per physician order. This affected one (Resident #68) out of two residents reviewed for skin management. The facility census was 99.

Inspectors wroteBased on review of a resident medical record, observations, staff interviews, and review of facility policy, the facility failed to administer oxygen as ordered for a resident. This affected one resident (#24) out of one resident reviewed for oxygen. The facility census was 99 residents.

Inspectors wroteBased on observation, interview, record review, and review of manufacture guidelines, the facility failed to ensure insulin was primed prior to administration. This affected one (Resident #3) out of three residents observed for medication administration. The facility census was 99.

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure staff maintained appropriate Personal Protective Equipment (PPE) for a resident on precautions. This affected one resident (Resident #06) of 22 residents in the survey sample.

Inspectors wroteBased on record review, review of the facility Self-Reported Incidents (SRI), review of the facility investigation, review of facility policy and procedure, resident interview, and staff interview, the facility failed to ensure Resident #100 was free from resident to resident physical abuse. Actual harm occurred on 02/03/25 when Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100 causing a fall and a right femur fracture. This affected one (Resident #100) of six residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on medical record review, review of a facility submitted Self-Reported Incident (SRI), hospital record review, interviews with staff, review of incident reports, and facility policy review, the facility failed to ensure care was delivered, as assessed and care planned for, utilizing the appropriate number of staff assistance during the provision of care for Resident #10. This resulted in actual harm when Resident #10 was provided care by one facility Certified Nursing Assistant (CNA) #100, who repositioned and provided incontinence care on 03/27/25 at approximately 10:00 A.M. and when Resident #10 was provided a bed bath and hair care on 03/27/25 at approximately 2:45 P.M. by one Hospice Aide #115 resulting in a comminuted femur fracture, a fracture where the bone breaks into three of more pieces often the result of major impact injury. [...]

Inspectors wroteBased on staff interviews, review of self-reported incident investigations (SRI) and policy review, the facility failed to ensure allegations of abuse, neglect, misappropriation and injuries of unknown origin were thoroughly investigated and interventions put in place. This affected eight Residents (#20, #21, #33, #48, #52, #54, #89 and #100) of nine reviewed for abuse, neglect and misappropriation investigations. The facility census was 96.

Inspectors wroteBased on staff interview, resident interview, family interview, review of the self-reported misappropriation incident investigation and review of the abuse policy, facility failed to ensure allegations of misappropriation were reported to the state agency in a timely manner. This affected one (Resident #89) of one reviewed for misappropriation. The facility census was 96.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure call lights were in reach and accessible for resident use. This affected two residents (#35 and #54) of two observed laying in their bed in their rooms. Facility census was 96.

Inspectors wroteBased on personnel file review, staff interview and review of a job description, the facility failed to ensure a qualified Activity Director (AD) was in place to oversee the facility's overall activity services. This had the potential to affect all 99 resident residing in the facility. The census was 99.

Inspectors wroteBased on observation, staff interview, medical record review, policy review, and review of manufacturer's guidelines, the facility failed to ensure medications were labeled and stored appropriately per manufacturer's guidelines and failed to ensure medication carts were secured when not in use. This had the potential to affect all residents residing in the facility. The facility census was 99 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to prevent clean equipment and utensils from contamination, failed to maintain kitchen equipment in operating condition, and failed to follow proper datemarking procedures. This had the potential to affect all residents with the exception of Residents #26 and #90 who receive nothing by mouth. The facility census was 99 residents.

Inspectors wroteBased on facility document review and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all residents residing in the facility. The facility census was 99.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a clean and homelike environment for seven (#18, #26, #35, #44, #78, #90, and #92) residents, all residents were screened during the annual survey. The facility census was 99.

Inspectors wroteBased on medical record review, observation, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had four medication errors of 31 opportunities for an error rate of 12.9 %. This affected four (Residents #64, #27, #08, and #49) of five residents reviewed for medication administration. The facility census was 99 residents.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy review, the facility failed ensure residents with physician's orders for enhanced barrier precautions (EBP) had appropriate signage outside the room indicating the precautions and failed to ensure containers of appropriate personal protective equipment (PPE) was available outside the residents' rooms. This affected three (Residents #1, #38, and #72) of 10 facility-identified residents with physician's orders for EBP. The facility also failed to ensure staff performed proper hand hygiene and followed appropriate infection control practices during wound care. This affected one (Resident #72) of six residents reviewed for wounds. The facility failed to ensure staff discarded gloves and performed hand hygiene after providing care. This affected two (Residents #1 and #34) of 25 residents sampled. [...]

Inspectors wroteBased on record review, family interview, staff interviews, and policy review the facility failed to make a life insurance policy payment from a facility managed account for one resident (Resident #9) out of five residents reviewed for personal funds. The facility census was 99.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the failed to ensure staff notified resident physicians of abnormal lab results in a timely manner. This affected one (Resident #72) of 25 residents sampled. The facility census was 99 residents.

Inspectors wroteBased on observation, record review, staff interview, policy review, and review of the facility assessment, the facility failed to effectively communicate with Resident #34. This affected one (Resident #34) of two residents reviewed for communication. The facility identified four residents who spoke an alternate language. The facility also failed to provide necessary assistance to maintain personal hygiene for one (Resident #35) of 25 reviewed. The facility census was 99.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to provide activities to meet the needs and preferences of the residents. This affected three (Resident #27, #45, and #72) of 32 residents observed for activities. The Census was 99 Findings Include: 1. Review of Resident #27's medical record revealed an admission date of 03/14/23. Medical diagnoses included dementia, depression, osteoarthritis, and hypertension. Review of Resident #27's MDS Medicare/5-day assessment, dated 07/02/24, revealed the resident had a BIMS score of 11, indicating moderately impaired cognition. Review of Resident #27's Activity Assessment, dated 02/06/2, revealed the resident's former occupation was a carpenter and he had current interests in reading, music, spiritual/religious activities, and watching television and movies. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physicians orders in obtaining daily weights. This affected one (Resident #4) of 25 residents records reviewed. The census was 99.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to assist Resident #78 with applying his corrective lenses. This affected one (Resident #78) of two residents reviewed for communication-sensory. The facility census was 99.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to maintain interventions to promote healing of pressure ulcers. This had the potential to affect three (Resident #1, #18 and #90) of four residents reviewed for pressure ulcers. The Census was 99.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure tube feedings were administered at the rate ordered by the physician. This affected one (Resident #26) of two facility-identified residents with orders for tube feeding. The facility census was 99 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors related to insulin administration. This affected one (Resident #49) of five residents reviewed for medication administration. The facility identified eight residents whose medication regimens required insulin injections. The facility census was 99 residents.

Inspectors wroteBased on review of facility documents and staff interview, the facility failed to ensure transfer agreements were in place. This had the potential to affect all residents who reside in the facility. The facility census was 99 resident.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of personnel files, review of the Ohio Department of Health (ODH) Nurse Aide Registry, and staff interviews, the facility failed to ensure that three State Tested Nursing Aide's (STNA) registrations were not expired. This affected three (STNA #36, #123 and #131) out of three STNA's reviewed for active registrations and had the potential to affect all residents residing in the facility. The facility census was 97.

Inspectors wroteBased on observation, staff interview, policy review, and review of the Centers for Disease Control (CDC) guidance and COVID-19 Data Tracker, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 95 residents residing in the facility.

Inspectors wroteBased on record review, observations, and staff and resident interviews, the facility failed to ensure resident rooms and facility corridors, lobby and unit hallways temperatures were between 71 to 81 degrees Fahrenheit. This affected two (Resident #30 and #31) of 25 residents reviewed for physical environment. The facility census was 95.

Inspectors wroteBased on observation, medical record review, resident and staff interview, review of the resident council minutes, and policy review, the facility failed to ensure activities were provided for cognitively impaired residents and provided according to the activity calendar. This affected two (#36 and #41) of four residents reviewed for activities. The facility census was 95.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure call lights in the bathrooms were functioning properly for two of 25 bathrooms reviewed during the annual survey. The facility census was 95.