Landmark Of Collins

Based 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.Findings include:A review of the facility's policy, Food Storage Labeling revised August 2024, revealed, .The facility will ensure the safety and quality of food by following good storage procedures.Procedure.7. Recommended Food Storage Chart.c. Steps to use the chart.iii. Use the calendar to select the recommended date to discard.d. discard foods that are found to have exceeded their storage time.8. Rotation a. First In, First Out method is used to rotate food in all storage areas i. Identify the food item's use by date or expiration date .On 09/15/2025 at 10:18 AM, during the initial tour of the dietary department with the Dietary Manager (DM), a gallon of whole milk in cooler #3 was observed with a manufacturer's expiration date of 09/14/2025. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings include:On 9/15/25 at 2:50 PM, during an observation and interview with Laundry Worker (LW) #1, she was delivering clean clothes to residents' rooms while holding the clothes close to her body, so that the clothes touched her uniform during four (4) delivery stops. LW #1 stated she had been trained not to allow residents' clothing to touch her clothing, as this could spread germs and infection. She reported that staff were in-serviced monthly on infection control practices.On 9/18/25 at 9:33 AM, during an interview with the Infection Prevention (IP) Nurse, she acknowledged that LW #1 failed to handle the clean laundry in a manner that would prevent infection. The IP Nurse stated she provided monthly in-service training on infection control and expected staff to follow guidelines to keep clean clothing away from their uniforms.On 9/18/25 at 9:37 AM, during an interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: A review of the facility's policy, Food Service Operational Standards for Purchasing, Cooking and Storage, revised 9/12, revealed, .The facility stores .food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety Procedure .3. Storage .f. Follow First In first Out (FIFO) . On 4/30/24 at 9:08 AM, an observation and interview with the Dietary Manager (DM) revealed the following: Refrigerator #1: One (1) unopened plastic bag of purple cabbage, one (1) unopened plastic bag of carrots strips, and six (6) unopened plastic wrapped heads of iceberg lettuce with no use-by or discard date. On 5/1/24 at 8:00 AM, an observation of a shelf located outside the pantry door, contained a plastic bin with 17…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The resident ate her salad and did not eat any other items on the meal tray. Resident #4's sister brought her lunch from home. Record review of the Lunch meal tray ticket for Resident #4, dated 4/30/24, revealed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Record review of a Departmental Note, dated 11/21/23 at 5:13 AM, for Resident #9 revealed, resident refused to allow his labs to be drawn this morning . Record review of a Departmental Note, dated 12/12/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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) Findings include: A review of the facility's policy, Food Service, revised 8/00 revealed Purpose: To meet the nutritional needs of each resident. To provide a well-balanced, flavorful and varied food service program . Resident #4 On 04/30/24 at 12:14 PM, in an observation and interview, Resident #4 was eating lunch in the dining room. Resident #4 had refused to eat the spaghetti with meat sauce, corn bread and ice cream and had her sister to bring her lunch from home. The resident said the food was bland with no taste most of the time because the facility did not season the food. She stated she had complained to the nursing staff and the Dietary Manager (DM) several times. A record review of the Face Sheet revealed the facility admitted Resident #4 on 3/19/24 with current medical diagnoses including Dysphagia and Anorexia. A record review of the admission Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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) Findings include: Review of facility's policy, Blood Glucose Quality Control, revised 01/24, revealed, .Maintenance of Blood Glucose Monitoring Systems Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe . Record review of the General Guidelines for Use for the Super Sani-Cloth Germicidal Disposable Wipe, dated 2021, revealed, .4. Allow treated surface to remain wet for two (2) minutes. Let air dry . On 5/1/24 at 10:47 AM, during an observation, Licensed Practical Nurse (LPN) #3 used a glucometer to perform an accucheck on Resident #32. After LPN #3 performed the accucheck, she returned to the medication cart, applied clean gloves, and obtained a Super Sani-cloth disposable wipe from the container. LPN #3 cleaned the glucometer for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 . Review of the facility's policy Fall Prevention and Management Program with the latest revision date of 09/18 revealed, .will be used to develop interventions after each fall and for care plan revisions .Management…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 . A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual, dated October 2019, revealed, .The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . A record review of the Face Sheet revealed the facility admitted Resident #3 on 03/20/2014. A record review of Resident #3's last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. If any skin concerns are noted, they are to be reported immediately to the designated nurse verbally and via the kiosk in electronic facilities . On 06/06/22 at 11:33 AM, the State Agency (SA) observed wound care for Resident #30 performed by the Director of Nursing (DON). The SA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufactured use-by date or expiration date . 4. Monitoring storage temperatures .b. Temperatures in food storage units are monitored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.