Life Care Center of Collegedale

In the surveyor’s words

From the most serious findings on record at Life Care Center of Collegedale, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 5, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure expired food items were discarded for 3 residents (Resident #20, Resident #70 and Resident #28) of 11 residents' personal refrigerators observed, failed to maintain safe food storage in the dietary department and failed to maintain sanitary kitchen equipment which had the potential to effect 111 of 111 residents.The findings include: Review of the facility's policy titled, Resident Refrigerators, revealed .The facility will .Store, prepare, distribute and serve food in accordance with professional standards for food service safety .Facility staff will check individual food items weekly for expiration dates and discard outdated food promptly from the residents' personal… […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2023

  Based on facility policy review, observations, and interview the facility failed to maintain a sanitary kitchen which had a potential to effect 114 of 116 residents of the facility. The findings include: Review of the facility policy titled, Sanitation and Maintenance, revised 11/4/2022, showed .Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state and local requirements . All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting. During an observation of the kitchen on 3/28/2023 at 11:09 AM, showed the following cooking pans were stacked and stored wet: -6 full size pans, -4 1/3 size pans -8 1/6 size pans. […]

• No harm, potential for more than minimal, patternF657Mar 29, 2021

  Based on review of facility policy, medical record review, and interview, the facility failed to revise the care plan for 1 resident (Resident #1) with a newly developed pressure ulcer, and failed to revise the care plan for 3 residents (Resident #1, Resident #2, and Resident #5) with significant weight loss of 6 residents reviewed. The findings include: Review of a facility policy Resident at Risk Meeting (RAR) Revised 1/22/2019, showed .This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues .The care plan is updated during the meeting. […]

• No harm, potential for more than minimal, patternF692Mar 29, 2021

  Based on review of facility policy, medical record review, observations and interviews, the facility failed to order a nutritional supplement recommended by the Registered Dietician (RD) for 2 residents (Resident #1 and Resident #5); failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2) of 6 residents reviewed for nutrition. The findings include: Review of a facility policy Resident at Risk Meeting (RAR) Revised 1/22/2019 showed .This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues .The review list includes but is not limited to the following: New admissions for a minimum of one… […]

• No harm, potential for more than minimal, patternF867Mar 29, 2021

  Based on facility policy review, review of Quality Assurance Performance Improvement (QAPI) documents, medical record review, and interview, the facility's QAPI committee failed to monitor facility identified ongoing concerns with obtaining accurate weights and nutritional supplements for residents with significant weight loss for 3 residents (Resident #1, Resident #2, and Resident #5) of 6 residents reviewed for nutrition. The findings include: Review of a facility policy Performance Improvement Projects (PIPs) dated 12/28/2020, showed .the facility will conduct Performance Improvement Projects .designed with a systemic approach to improve care and services in areas that are identified as an opportunity for improvement. […]