Collinwood Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Collinwood Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF742May 22, 2025

  Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (Resident #2) of six residents reviewed for behavioral health services. 1. The facility failed to ensure Resident #2 was not roommates with another resident who affect her diagnoses of anxiety and PTSD, when she told staff she felt anxious about the new roommate, Resident #1. 2. The facility failed to ensure Resident #2 was immediately provided behavioral health services or put interventions in place after having suicidal ideations and threatening to harm herself. […]

• Immediate jeopardy, patternF684Feb 18, 2022

  Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #16) of five residents reviewed for quality of care. The facility failed to ensure Resident #16, who was immunocompromised, received treatment and care for his Central Venous Catheter (CVC), including routinely monitoring and assessing the site for infections or complications, and changing the dressing. The facility failed to notify the provider of a new central line, obtain orders, and care plan Resident #16's central line since his return from the hospital on 02/05/22. […]

• Immediate jeopardy, isolatedF600May 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 2 (Resident #2 and Resident #3) of 3 residents reviewed for abuse. 1. The facility failed to ensure Resident #3 was free from abuse on 01/05/25, when Resident #1 told Resident #3 she would stab her. 2. The facility failed to ensure Resident #2 was free from abuse on 01/07/25, when Resident #1 walked into Resident #2's room and hit her repeatedly in the head, with a pole like object causing her to be sent to the hospital, where she was diagnosed with an eye injury, bruises, and abrasions. An Immediate Jeopardy was identified on 05/21/2025. The IJ template was provided to the facility on [DATE] at 4:38 PM. […]

• Immediate jeopardy, isolatedF656May 22, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #1 and Resident #2) of 6 residents, reviewed for care plans. 1. The facility failed to address Resident #1's verbal abuse towards others and threat toward Resident #3, on 01/05/25, on the comprehensive care plan. 2. The facility failed to address Resident #2's suicidal ideations on 09/26/24, 12/11/24, and 01/03/25 on the comprehensive care plan. An Immediate Jeopardy was identified on 05/21/2025. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2024

  Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to discard expired foods according to guidelines. The facility failed to discard dented cans according to guideline. The facility failed to ensure all damaged eggs were removed from the other eggs stored in its original container. […]