Colonial Nursing Home

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary kitchen related to testing the dishwasher sanitation level with faulty test strips in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect the 26 of 29 residents in the facility who received food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide at least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208)

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's physician was notified of medication being held for 1 of 5 residents reviewed for unnecessary medications. (Resident 183)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was implemented for a resident with a diabetic foot ulcer for 1 of 12 resident care plans reviewed. (Resident 13)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a reddened sclera (white part of eyeball) of the eye was assessed and monitored for 1 of 2 residents reviewed for vision/hearing services. (Resident 20).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services related to not obtaining treatment orders for a wound vac for 1 of 4 residents reviewed for pressure ulcers. (Resident 183)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there were orders and/or monitoring completed for a resident on a fluid restriction. (Resident 183)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident 9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the disposal of used lancets into the garbage can for 1 of 1 glucometer (machine used to test blood sugar levels) testing observed. (Resident 183, RN 1)

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to dirty kitchen walls and floors in the kitchen. (Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (Agency CNA 1 and Agency CNA 5) when providing care to residents (Resident D and F) who were in Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for EBP. The facility also failed to ensure hand hygiene was completed by a staff member (Agency CNA 1) after care had been completed on a resident (Resident B) and care initiated on another resident (Resident C) and to ensure a personal care item was used for only 1 resident and was not used for multiple residents (Residents B, C, G, D, and H) by a staff member related to incontinent wipes. (Agency CNA 1)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the residents' environment was clean and in good repair related to scraped paint, nicks and gouges on the walls, dried feeding on the feeding poles, a oxygen concentrator and on the floor, debris and trash on the floors, a dirty floor mat, and a stool with a cracked vinyl seat for 1 of 2 floors. (First Floor). During an environmental tour with the Director of Maintenance/Housekeeping on 3/18/25 from 12:59 through 1:29 p.m., the following was observed: a. room [ROOM NUMBER] - There were paint scrapes behind the head of the bed. During an interview at the time of the observation, the Director of Maintenance/Housekeeping acknowledged the scrapes and indicated when the residents were discharged or moved rooms, the walls were repaired. b. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had a clean and homelike environment related to soiled bed linens for 2 of 8 residents reviewed for a clean and homelike environment. (Residents B and D)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents who were dependent on staff received incontinence care for 2 of 7 residents reviewed for activities of daily living. (Residents E and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities were implemented for a cognitively impaired dependent resident for 1 of 1 resident reviewed for activities. (Resident 14)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's wounds were assessed and monitored for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident 10)

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow up on an Occupational Therapy recommendation for a resting hand splint for 1 of 2 residents reviewed for position/mobility. (Resident 8)

Inspectors wroteBased on record review and interview, the facility failed to ensure catheter care was completed and urinary output was recorded for 1 of 3 residents reviewed for urinary catheters. (Resident D)

Inspectors wroteBased on observation, record review and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 resident reviewed for intravenous care. (Resident 25)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 22)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record was complete and accurate related to incontinence care logs, for 1 of 3 residents reviewed for incontinence care. (Resident B)

Inspectors wroteBased observation, record review, and interview, the facility failed to ensure food was served and stored under sanitary conditions related to unlabeled and expired food in the refrigerator, dirty refrigerator shelves, lack of hand hygiene during food preparation, dirty utensil bins and a broken oven door. This had the potential to affect 30 residents who received food from the kitchen. (The Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208)

Inspectors wroteBased on observation and interview, the facility failed to maintain a functional, safe, and homelike environment related to bent or loose baseboard heater covers, marred and gouged doors and walls, a ripped and torn wheelchair armrest, loose thermostat cover and broken floor tiles for 4 of 30 resident rooms (Rooms 111, 112, 124 and 202) and 2 of 2 units (first and second floor).

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was in place for a resident receiving an antipsychotic medication for 1 of 13 residents whose care plans were reviewed. (Resident 33)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was invited to their care plan conference for 1 of 13 residents whose plans of care were reviewed. (Resident 19)

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions related to lack of planning, education, and supplies for a resident's caregivers on how to care for the resident's ileostomy before the resident's discharge home from the facility for 1 of 1 residents reviewed for ileostomy care. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharged resident had a discharge summary completed, including a post-discharge plan of care with the resident and responsible party, for 1 of 2 residents reviewed for discharges. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a lymphedema sleeve was applied as ordered and a scabbed area was assessed and monitored for 1 of 1 residents reviewed for edema and non-pressure skin conditions. (Resident 25)

Inspectors wroteBased on record review and interview, the facility failed to ensure pain medications were available for a newly admitted resident experiencing pain for 1 of 1 residents reviewed for pain management. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to labs not completed as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in form to meet individual needs related to not following a recipe for pureed food. This had the potential to affect 1 resident who received a pureed diet. (Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to improper cleaning of reusable equipment for 3 of 4 medication pass observations. (RN 1, LPN 1)

Inspectors wroteBased on observation and interview, the facility failed to have accurate daily nurse staffing postings. This had the potential to affect all 33 residents residing in the facility.