Landmark of Collins

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to remove expired food items from the refrigerator by the manufacturer's expiration date, maintain the refrigerator in a clean condition free from spills, and store food according to manufacturer's instructions for one (1) of four (4) survey days.

Inspectors wroteBased on observation and staff interview, the facility failed to handle residents' clean clothing in a manner that prevented the possible spread of infection for one (1) of four (4) days of survey.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety as evidenced by food items not dated and spoiled foods for two (2) of three (3) kitchen observations.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to honor the resident's right for choices as evidenced by serving a meal that included a known dislike for one (1) of (14) sampled residents. (Resident #4) Findings Include: Review of the facility's policy, Dietary Services, revised 11/17, revealed, . Food likes, dislikes and eating habits are assessed by the Nursing and Dietary Departments. This information is recorded in the resident's Medical Record . During an observation and interview on 4/30/24 at 12:14 PM, Resident #4 was served spaghetti with meat sauce on her meal tray. Resident #4 stated that had told the staff and the Dietary Manager (DM) several times that she did not eat noodles or rice. The resident's meal consisted of spaghetti with meat sauce, lettuce and tomato salad, cornbread, and ice cream with tea and water. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure physicians orders for laboratory tests were followed for one (1) of five (5) residents reviewed for unnecessary medications. (Resident # 9) Findings Include: Review of the facility's policy, Physician Orders, revised 9/23, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner . Record review of the Physician's Orders, for the month of April 2024 revealed Resident #9 had Physician's Orders, dated 11/6/20 for a Vitamin D level yearly in November, Thyroid Stimulating Hormone (TSH) yearly in November, and a Basic Metabolic Panel (BMP) every six (6) months in November and May. Resident #9 also had a Physician's Order, dated 9/22/22 for a Complete Blood Count (CBC) every 6 months in November and May. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide palatable meals for three (3) of 14 sampled residents reviewed. (Resident # 4, Resident #14, and Resident # 50)

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection, as evidenced by failure to clean a glucometer device according to manufacturer's guidelines for one (1) of two (2) observations. (Resident #32)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was reviewed timely for one (1) resident, Resident #39, and revised for two (2) residents, Resident #39 and Resident #103, out of four (4) residents sampled for falls. Findings Include: Review of the facility's policy, Care Plan Process with a revision date of 08/17 revealed, .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .Re-evaluates the resident's status at prescribed intervals (i.e. quarterly, annually, or if a significant change in status occurs) .Interventions are actions that should promote meeting the established goal . [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) for one (1) of 38 residents reviewed for comprehensive assessments, with the potential to affect 57 residents. Resident #3 A record review of the facility's policy MDS Process, with a latest revision date of 12/20, revealed, The Assessment Nurse/ Nurse Case Manager will set the Assessment Reference Date on an allowable date with input from the interdisciplinary team and communicate scheduled assessments to the interdisciplinary team. The RAI (Resident Assessment Instrument) manual is the source document to be used for further MDS coding guidelines, time schedules and requirements . [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to prevent the development of an avoidable pressure ulcer on a resident with an immobilization brace for one (1) of three (3) facility acquired pressure ulcers reviewed. Resident #30 Findings Include: Review of the facility's policy, Prevention and Treatment of Skin Issues with a latest review date of 8/21 revealed, Policy: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .C. monitoring of skin integrity. The skin will be observed daily during care by the nursing assistants. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to discard expired food items, ensure daily temperature logs for the freezer were completed, and failed to label and date refrigerated items for one (1) of four (4) kitchen observations. Findings Include: A record review of the facility's policy Food Storage Labeling, with a revision date of 05/18, revealed, Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures Procedure: 1. Labeling . a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food Date of storage .3. Rotation .b. [...]