The Colony Healthcare Center

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain infection control procedures while administering medications. This affected one resident (Resident #29) out of four residents observed for medication administration. The facility census was 108.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to maintain the kitchen and nursing unit refrigerator and microwave on unit D in a clean and sanitary manner. This had the potential to affect all residents receiving food from the facility. The facility census was 108.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to maintain an effective pest control program to prevent flies in the facility. This had the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected six (Residents #2, #38, #67, #94, #102, and #116) of 108 residents reviewed for environment. The facility census was 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure intravenous antibiotics were administered according to physician orders for Resident #99. This affected one (Resident #99) of two residents reviewed for antibiotics. The facility census was 108.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure the correct serving sizes were served for the pureed diet. This affected 10 (Residents #14, #33, #36, #64, #71, #82, #84, #86, #91, and #105) who received a pureed diet. The facility census was 108.

Inspectors wroteBased on record review and interview, the failed to ensure an as needed (PRN) psychotropic medication had a stop date for Residents #9 and #107. This affected two (Residents #9 and #107) of five residents reviewed for unnecessary medications. The facility census was 108.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure Residents #22, who was dependent on staff for personal hygiene, was provided adequate and timely nail care. This affected one (Resident #22) of two residents reviewed for activities of daily living. The facility census was 108.

Inspectors wroteBased on record review, observation and interview, the facility failed to identify maggots in Resident #5's wound. This affected one (Resident #5) of two residents reviewed for wound care. The facility failed to ensure blood pressure medication was administered according to physician orders for Resident #5. This affected one (Resident #5) of three residents observed for medication administration. The facility failed to ensure Resident #54's chole drain dressing was performed according to physician orders. This affected one (Resident #54) of one resident observed for chole drain dressings. The facility census was 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure intravenous antibiotics were administered according to physician orders for Resident #99. This affected one (Resident #99) of two residents reviewed for antibiotics. The facility census was 108.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure staff treated Resident #109 with dignity and respect. This affected one resident (#109) out of three residents reviewed for abusive treatment in the facility. The facility census was 108.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure Resident #83's sponsor was notified of significant changes in Resident #83's condition. This affected one resident (#83) out of three residents reviewed for changes in condition. The facility census was 108.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all medications were stored and labeled as required. This affected five (Residents #47, #48, #49, #50, #51) of 10 residents reviewed.

Inspectors wroteBased on observation, interview, and policy and procedure review, the facility failed to ensure staff maintained infection control standards when administering medications. This affected one (Resident #47) of five residents observed for medication administration.

Inspectors wroteBased on record review and interview the facility did not ensure the activity director was qualified to establish and provide a therapeutic activity program to meet the needs and interests of the resident population in the facility. This affected all 110 residents living in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff were competent to complete their duties. This had the potential to affect all 109 residents who received meals from the kitchen except one resident (Resident #98) who the facility identified as eating nothing by mouth. The census was 110.

Inspectors wroteBased on observation, interview, review of facility policy, and review of the Ohio Uniform Food Safety Code, the facility failed to ensure food items were stored at least six inches off the floor. This had the potential to affect all 109 residents who received food from the kitchen and excluded Resident #98 who received nothing by mouth. The census was 110.

Inspectors wroteBased on observation, record review and interviews, the facility administrator did not ensure a qualified activity director was hired to administer a therapeutic activity program to meet the needs and interests of the residents. This had the potential to affect all 110 residents living in the facility.

Inspectors wroteBased on review of the resident council meeting minutes and resident and staff interviews, the facility failed to ensure ongoing communication to residents about their various rights at the resident council meetings. This affected 15 residents (Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) of 15 residents present at the resident council meeting. The facility census was 110.

Inspectors wroteBased on record review, observations and interviews the facility failed to provide therapeutic activities as scheduled on the activity calendar and failed to provide evening activities to meet the needs and preferences of all the residents in the facility. This affected 15 residents (#12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) residing on the A,B and C units and had the potential to affect all residents residing on the A, B, C units excluding Residents #16, #41, #264, #80, #2, #77, #45, #39, #66, #15, #42, #74, #89, #38, #86, #35, #37, #90, #91, #69, #93, #92, #75, #97 and #6 who resided on the secured unit D. The facility census was 110.

Inspectors wrote3. Resident #80 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorder, anxiety, congestive heart failure, chronic obstructive pulmonary disease, and major depression. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/04/23, revealed the resident was moderately cognitively impaired and exhibited no behaviors. Review of the physician's orders revealed Resident #80 was receiving an antipsychotic medication for a diagnosis of delusional disorder. Review of the August, September and October 2023 Medication Administration Record (MAR) for Resident #80 for behavior monitoring revealed the resident had four days with behaviors in October, and no behaviors were exhibited in September or August. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected three residents (#14, #24, and #94) of five residents reviewed for food and nutrition. The census was 110.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to provide snacks per resident preferences and the plan of care. This affected seven (#12, #51, #62, #67, #71, #79, and #85) of seven residents reviewed for snacks and had the potential to affect all residents (except Resident #98) residing in the facility. The census was 110.

Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure the authorized parties were notified of changes in the resident's treatment for Resident #15 and Resident #19. This affected two residents (Residents #15 and #91) of 26 residents reviewed for notification of change. The facility census was 110. Findings Include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Resident #15's family member was listed as the authorized primary contact. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. [...]

Inspectors wroteBased on staff interview and record review the facility failed to ensure resident assessments were accurate. This affected two residents (Residents #15 and #40) of 26 residents reviewed for resident assessments. The facility census was 110. Findings Include: 1. Review of the medical records revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Review of the nursing progress notes for Resident #15 from admission through the present revealed on 09/06/23 the resident had increased confusion, wandering, exit seeking, agitation, and believed others were stealing her belongings. No other behaviors were documented. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident who was dependant on staff for assistance with activities of daily living (ADLs) received the assistance needed with bathing and personal hygiene. This affected one resident (Resident #68) of two residents reviewed for ADLs. The facility census was 110.

Inspectors wroteBased on closed medical record review and interview, the facility failed to properly assess and document skin concerns for Resident #363. This affected one resident (#363) out of five residents reviewed for skin concerns. The facility census was 110.

Inspectors wroteBased on medical record review and interviews, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one resident (#24) of one resident reviewed for hearing ancillary services. The census was 110.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a thorough investigation to identify and analyze hazards and risk factors for falls was conducted regarding falls for Resident #15, #94 and #102. This affected three residents (Resident #15, #94, and #102) of five residents reviewed for falls. The facility census was 110.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order was obtained for oxygen administration. This affected one resident (Resident #54) of three residents reviewed for oxygen therapy. The facility identified six other residents (Residents #13, #17, #34 #57, #67 and #79) identified by the facility as using oxygen therapy. The facility census was 110.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a physician's order was obtained for dialysis treatment for two residents (Residents #51 and #102) and that pre and post dialysis assessments were completed for Residents #40, #51 and #102. This affected three residents (#40, #51 and #102) of three residents reviewed for dialysis treatment. The facility census was 110.

Inspectors wroteBased on closed record review and interview, the facility failed to provide medication as ordered for Resident #363. This affected one (Resident #363) out of five residents reviewed for medications. The facility census was 110.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure insulin was given per physician's orders. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure medications were stored and labeled in a manner that prevented the risk of residents receiving insulin that belonged to another resident. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110.

Inspectors wroteBased on review of the Payroll Based Journal (PBJ) report, review of staffing schedules, review of the facility assessment and interview, the facility failed to ensure accurate PBJ reporting. This had the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on record review, observations, and interviews the facility failed to provide restorative nursing services to Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #57. This affected six (Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #) of six residents reviewed for restorative nursing programs.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately obtain, monitor and assess weight changes for Residents #22, #30, #44, #50 and #58. This affected five residents (Residents #22, #30, #44, #50 and #58) of seven residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident narcotics on the controlled drug administration records were signed off in a timely manner for Resident #3, #22, #30, #50, #51, #63 and #68 and failed to ensure Resident #47 received diuretic medication as ordered. This affected seven residents (Resident #3, #22, #30, #50, #51, #63 and #68) of seven residents reviewed on the facility B hall for medication storage, and one resident (Resident #47) of five residents reviewed for medication.

Inspectors wroteBased on record review and interview, the facility failed to implement a restorative nursing program after reviewing it as a systemic problem at the Quality Assurance and Assessment meeting. This affected six residents (#14, #37, #38, #47, #50 and #57) of six residents who were identified by the facility as needing a restorative nursing program.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure a family member visiting Resident #182 adhered to the proper use of personal protective equipment in a quarantine room for droplet isolation for potential COVID 19, and also failed to ensure clean hoyer pad straps were stored without the straps sitting on the floor. This affected one resident (Resident #182) of three residents reviewed for transmission based precautions and had the potential to affect all 15 of 15 residents (Resident #7, #13, #29, #32, #53, #55,#54,#61, #62, #63, #67, #180, #181, #182, and #184) who used hoyer pads.

Inspectors wroteBased on record review, observation and interviews, the facility failed to maintain a food processor, used to make pureed foods, in proper working order. This had the potential to affect all 10 residents (#8, #10, #19, #20, #27, #40, #53, #54, #62 and #184) on a pureed diet.

Inspectors wroteBased on record review, observation, and interview, the facility failed to update the plan of care for Resident #50 to establish an objective, measurable weight goal for a physician prescribed weight loss diet. This affected one (Resident #50) of seven residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bladder program was implement to restore Resident #1 bladder function to his base line. This affected one (Resident #1) of two residents reviewed for decline in activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient eating assistance to Resident #37. This affected one (Resident #37) of eight residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #43 smoked safely. This affected one (Resident #43) of three residents reviewed for accident hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #32 had bowls for all meals to assist with eating. This affected one resident (Resident #32) of seven residents reviewed for nutrition.