Colonial Nursing and Rehabilitation Center

Based on facility policy review, record review, and interview, the facility failed to provide adequate assistance to prevent falls for 1 of 3 residents sampled for falls (Resident (R) 14). The findings include: Review of a facility policy titled, Falls Policy, last reviewed on 12/22/2025, revealed, The intent of this policy was to ensure the facility provides an environment that was as free from accident hazards as possible, over which the facility has control to prevent avoidable falls/accidents. The policy revealed, 2. A Care Plan would be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls, to the extent possible. Review of R14's admission Record revealed the facility admitted R14 on 05/06/2022. According to the admission Record, the resident had a medical history that included diagnoses of morbid obesity, left foot drop (difficulty in lifting the front part of the foot), and right foot drop. Review of an annual Minimum Data Set (MDS), with an Assessment Reference…

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, interview, record review and review of a manufacturer's instructions, the facility failed to ensure licensed nursing staff demonstrated competencies and skill set necessary to administer insulin via insulin injector pen for one (Licensed Practical Nurse (LPN) of two licensed nurses observed during the medication administration task for one of 11 residents observed during medication administration (Resident (R) 50). The findings include: Review of LPN1's Competency Assessment Insulin Administration document, dated 04/16/2026, revealed, A) Purpose revealed, To provide guidelines for the safe administration of insulin to residents with diabetes. The document revealed, B) Preparation included 5. The nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. The document indicated that the Director of Nursing (DON) assessed LPN1's ability to administer insulin via syringe but did not indicate the DON assessed the LPN's ability to administer insulin via a pen injector.…

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 reviews, and review of facility's policy, it was determined the facility failed to ensure residents had the right to formulate an advance directive for nine (9) of sixteen (16) sampled residents (Residents #7, #8, #15, #17, #145, #195, #32, #295, and #18). Review of the residents' medical records revealed there was no documented evidence to support the facility provided a written description of the facility's policies that would empower the residents to participate in their own health care and decision-making by formulating an advance directive. Additionally, the Director of Social Services and Recreation, who was responsible for discussing whether the residents wished to consider developing an advanced directive, stated she was unaware of the regulatory requirements concerning advanced directives and did not give the residents information on how to formulate an advance directive upon admission. The findings include: Review of the facility's policy titled, Health Care Decision Making,…

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, interview, record review, review of the facility's assessment, and review of the facility's policy, it was determined the facility failed to provide adequate staff to provide nursing and related services. Review of Resident Council Meeting Minutes revealed resident's voiced concern that call lights were not answered timely. Additionally, resident's were concerned there was not enough staff on the night shifts and weekends. The findings include: Review of the facility's policy titled, Nurse Scheduling and Timekeeping Process, revised 07/01/2022, revealed the facility would staff according to budgeted staffing levels and adjust schedules based on census. Budgeting and adjusting staffing levels were based on a combination of senses, acuity levels and regulatory requirements. The purpose was to ensure consistent quality care provided by all service locations and optimal utilization of employees. Review of the facility's policy titled, Staffing Center Plan , revised 08/07/2023, revealed the facility provided qualified and appropriate staffing levels to meet 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, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure standard and Enhanced Barrier Precautions were followed. Observation during initial tour of the facility, on 01/23/2024 starting at 8:45 AM, revealed there were no residents on Enhanced Barrier Precautions. However, observation on 01/24/2024 starting at 8:50 AM, revealed the North and South Halls, had nineteen (19) resident rooms with EBP signage, and two (2) Personal Protective Equipment (PPE) bins on the halls. The facility failed to follow the Centers for Disease Control (CDC) and Prevention guidelines related to residents with wounds/indwelling medical devices should be on EBP, regardless of MDRO colonization status and if infection or colonization with an MRDO. Additionally, observation on 01/23/2024 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 observations, interviews, and review of the facility's policy it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for three (3) of sixteen (16) sampled residents (Resident's #295, #195, and #17). Observations of Resident #295 and Resident #17, on 01/24/2024 and 01/25/2024, revealed the resident's catheter bags had no dignity cover in place. Observation during a lunch meal on 01/23/2024, revealed Resident #195 waited thirty-two minute for his/her meal tray, while other residents had been served their food in the dining room. The findings include: Review of the facility provided document titled, Resident Rights under Federal Law, dated 11/28/2016, revealed the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further, the resident also had the right to exercise his…

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, interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the care plans when changes occurred for one (1) of sixteen (16) sampled residents (Resident #18). On 01/25/2024, Resident #18 was assessed to be unable to transfer independently and was unable to stand or pivot with transfer. It was at that time, the resident required the use of the total body lift with the assistance of two staff for transfers. The facility; however, failed to ensure the resident's Comprehensive Care Plan was updated/revised to reflect the change in the resident's assessed needs. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised on 10/24/2022, revealed the facility would develop and implement a Baseline Person-Centered Care Plan within forty-eight (48) hours of admission for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of…

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 interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for one (1) of three (3) closed records (Resident #43). Review of Resident #43's closed record revealed there was no documentation to support the facility had developed a discharge plan for the resident upon admission. Further, the Social Service Director (SSD) stated she did not know how the resident's discharge plan was missed. The findings include: Review of the facility policy titled, Discharge Planning Process, revised 11/15/2022, revealed the facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, effectively transition them to post-discharge care, and reduce the factors leading to preventable readmissions. The policy further revealed within seventy-two (72) hours of admission the post admission family conference will be…

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, interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary care and services to ensure the residents had an effective communication system for one (1) of sixteen (16) sampled residents (Resident #30). Observation and an attempted interview with Resident #30, who was a Non-English speaking resident, on 01/23/2024 at 9:00 AM, revealed the resident was unable to communicate with the State Survey Agency (SSA) Surveyor due to not having access to a functioning communication system/device. The findings include: Review of the facility's policy titled Resident Rights Under Federal Law, revised 02/01/2023, revealed residents had the fundamental right to considerate care that safeguard their personal dignity along with respecting cultural, social, and spiritual values. The policy further revealed the facility must ensure that information was provided to each resident in a form and or manner the resident can access and understand, including in an alternative format or in a language that the resident could…

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.