Colonial Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure resident's personal funds were available during non-business hours for 1 (Resident #23) of 34 sampled residents. Total facility census was 63.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #65) of 1 resident reviewed for transfer/discharge. The total sample size was 63.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the Residents' status for 3 (#6, #17, and #57) of 34 sampled residents by failing:1. to ensure the Significant Change MDS assessments were correct for Resident #6 and Resident #17; and2. to ensure Resident #57's 03/23/2026 Quarterly MDS contained accurate diagnoses.

Inspectors wroteBased on interviews, record reviews, and investigations, the facility failed to ensure the development and implementation of the residents' person-centered plan of care for 3 (#23, #51, and #52) of 34 sampled residents by failing to:1. to develop and implement a care plan for Resident #23's dialysis needs;2. to develop and implement a care plan for Resident #51's ADL needs; and3. to monitor effectiveness of diabetic medications on Resident #52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 63 residents who resided in the facility. The facility failed to ensure:1. Expired Food items in the pantry were not available for use;2. Staff are wearing beard restraints to prevent hair from contacting food

Inspectors wroteBased on observation, record review, and interview the facility staff failed to use standard precautions by performing hand hygiene during medication administration for 4(Resident #9, Resident #11, Resident #38, Resident #47) of 4 residents observed. Review of policy Hand Hygiene Table dated January 2025 revealed, hand hygiene should be used between resident contacts- either antimicrobial Soap and Water or Alcohol Based Hand Rub. Observation of medication administration on 05/27/2026 with S7 LPN revealed that she did not perform hand hygiene by not washing or sanitizing her hands between medication administrations of the 4 observed residents. Interview on 05/27/2026 at 08:20 AM with S7 LPN confirmed, Absolutely, I should have used sanitizer between administrations of medication between residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident physical abuse, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #1, a cognitive resident, experienced psychosocial harm as a result of the physical abuse by staff. This deficient practice resulted in psychosocial harm to Resident #1 on 10/11/2025 at 1:15 p.m., when Resident #1 reported to S2 CNA that S3 CNA entered his room without invitation and intentionally poured water on him in an attempt to stop him from masturbating. Resident #1, who had a BIMS score of 15 (cognitively intact), was tearful and fearful following the physical abuse from S3 CNA. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure an allegation of abuse was reported immediately to the administrator of the facility for 1 (Resident #1) of 3 sampled residents reviewed for abuse. The facility failed to ensure staff reported an allegation of staff-to-resident abuse to facility Administrator.

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident's person centered plan of care was reviewed and revised to include approaches/ interventions to address the resident's self pleasuring behavior for 1 (Resident #1) of 3 sampled resident's care plans reviewed. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance. An interview on 11/20/2025 at 1:35 p.m., with S2CNA revealed Resident #1 masturbates in his room frequently. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision was in place for a cognitively impaired resident who was identified as being at high risk for elopement, exhibited exit seeking behaviors, and voiced a desire to leave the facility did not exit the building for 1 (#156) of 11 (#2, #3, #23,#24, #25, #38, #44, #47, #48, #156 and #157) residents at risk for elopement.

Inspectors wroteResident #25 Based on observation, interview, and record review, the facility failed to implement and monitor interventions to maintain proper hydration and nutrition for 2 (Resident #25 and Resident #8) of 2 residents reviewed for nutrition. The facility failed to: 1. Implement and monitor hydration consistent with Resident #25's assessed needs; and 2. Notify the Registered Dietician of Resident #8's change in nutritional needs.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 55 residents who resided in the facility. The facility failed to ensure: 1. Food items in pantry were stored in a sealed container; 2. Opened food items in refrigerator and freezer were labeled with an open date and stored in a sealed container; and 3. Snacks considered potentially hazardous food were stored appropriately.

Inspectors wrote3. Resident #11 A review of Resident # 11's medical record revealed an initial admission date of 12/08/2023 and re-admission date of 01/23/2025 with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, Phantom Limb Syndrome with pain, Peripheral Vascular Disease, acquired absence of right leg above knee, unspecified open wound of left great toe with damage to nail, subsequent encounter, cellulitis of left lower limb. On 05/28/2025 at 10:00 a.m. review of Resident #11's annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #11 had a BIMS score of 10, which indicated moderate cognitive impairment and had an open lesion on the foot. On 05/28/2025 at 11:04 a.m. [...]

Inspectors wroteOn 05/27/2025 at 11:30 a.m. observation of the facility kitchen revealed one live fly flying throughout the food preparation area. On 05/29/2025 at 09:08 a.m. observation of the facility kitchen revealed one live fly flying throughout the kitchen area. On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed the facility recently began having issues with live flies. S8 Dietary Manager confirmed she has observed live flies in kitchen area and the kitchen should always be free of flies or any other insects/pest, but was not. Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to provide an environment free of flies throughout the facility. This deficient practice had the potential to effect all 55 residents who resided in the facility.

Inspectors wroteResident #156 Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder. Review of Resident #156's admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. The MDS revealed Resident #156 was independent for transfers and used a walker for mobility. Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: willfully attempted to leave facility without notifying staff, wanted to be discharged back home. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to provide a necessary communication aid for 1 (#35) of 1 Resident reviewed for communication. The total sample size was 30.

Inspectors wroteBased on record review and interview, the facility failed to ensure 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) out of 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) nursing/direct care staff records reviewed, were re-trained on their policy & procedure for abuse, after an incident of staff to resident verbal abuse occurred for 1 (#1) of 3 (#1, #2, and #3) sampled residents. This deficient practice had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (Resident #18) of 2 (Resident #18 and Resident #20) sampled residents investigated for abuse. The facility failed to report an allegation of staff to resident abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #49) of 1 residents sampled for dental. The total sample size was 23 residents.

Inspectors wroteBased on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #18) sampled resident in a total sample of 23 residents. The facility failed to ensure a comprehensive care plan was developed for a resident newly diagnosed with Dementia.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided to meet professional standards of practice. The facility failed to accurately document administration of respiratory services provided for 1 resident (Resident #37) of 23 sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care to dependent residents for 1 (Resident #40) of 7 residents (Resident #10, Resident #18,Resident #28, Resident #40, Resident #44, Resident #53, and Resident #58) sampled for ADL's.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 2 of 2 medication carts.