Colonial Oaks Skilled Nursing and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to ensure Resident #331 received needed services and treatment for pain management of a right fractured hip by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide pain management consistent with professional standards of practice for a resident, following a fractured right hip, for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. Nursing staff failed to ensure severe pain was managed for Resident #331 by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. [...]

Inspectors wroteBased on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to have an effective system in place to obtain and provide pain management for Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide services that met professional standards for 1 (#51) of 36 sampled residents. The facility failed to ensure safe medication administration practices by leaving medication at the bedside.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure quarterly statements were provided for 2 residents (#35, #54) of 2 (#35, #54) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and or their responsible parties.

Inspectors wroteBased on record reviews and interviews the facility failed to develop resident's comprehensive person-centered care plans with a focus and appropriate approaches on bed rails/side rails for 3 (#8, #12, and #27 ) of 3 (#8, #12, and #27) residents reviewed for physical restraints.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide pharmaceutical services that assure the accurate administering of medications for 2 (#44 and #331) of 2 (#44 and #331) residents whose medications were reviewed. The facility failed to ensure administration of pain medication was accurately documented.

Inspectors wroteBased on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required.

Inspectors wroteBased on record review and interview the facility failed to have the six required staff members present for quarterly QAA (Quarterly Assessment Assurance) Committee meetings.

Inspectors wroteBased on record review, observations, and interview the facility failed to provide appropriate treatment and services for 1(#52) resident of 1(#52) resident reviewed for tube feedings. The facility failed to ensure Resident #52's tube feeding bag was changed every 24 hours.

Inspectors wroteBased on observations and interviews the facility failed to ensure facility's daily census and nurse/CNA (Certified Nurse Assistant) staffing information was clearly displayed in a visible place for residents and visitors to view at any given time.

Inspectors wroteBased on record review, observation and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure: 1. Kitchen staff properly monitored the chemical levels in the third compartment sanitization sink 2. the chest freezer remained free from ice buildup 3. expired/outdated food was removed from the chest freezer and 4. The chest freezer was free of spilled food items. This had the potential to affect any of the 77 residents who received trays out of the kitchen on 06/02/2025.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident fall was reported according to facility policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents for falls.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure services were provided to meet professional standards of quality as evidenced by failing to document a resident's fall and failing to assess a resident after a fall for 1 (#1) of 3 (#1, #2, #3) sampled residents. S3LPN failed to document a fall Resident #1 sustained on 11/18/2024.

Inspectors wroteBased on record review and interviews the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to the state agency for 1 (#2) of 4 (#1,#2, #3, #4) residents reviewed for misappropriation of resident property.

Inspectors wroteBased on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure Quarterly assessments were completed no later than 14 days after the ARD (Assessment Reference Date) for 5 (#54, #14, #18, #7, #46) of 8 residents (#54, #14, #17, #27, #18, #7, #46, #52) reviewed for Resident Assessment.

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to develop an individualized, person-centered plan of care to meet the needs of 1 (#15) resident out of 15 residents (#1, #3, #9, #15, #19, #24, #38, #45, #65, #69, #70, #71, #53, #56, and #322 ) who were reviewed for plan of care. There were 69 residents residing in the facility. The facility failed to ensure the plan of care included an accurate assessment of resident (#15) that he did not have teeth when he does have teeth and required assistance with his oral care.

Inspectors wroteBased on resident council minutes, resident council response sheets and interviews the facility failed to consider the views of residents and respond promptly to the resident group with written documentation or a reasonable response to issues or concerns presented in resident council meetings.

Inspectors wroteBased on interviews, observations, and record review the facility failed to ensure dietary choices were honored for 1 of 1 (#49) resident reviewed for dietary choices. The facility continued to serve resident #49 food she disliked and did not eat. The facility had a total census of 77 resident.

Inspectors wroteBased on observations and interview, the facility failed to ensure dietary services were provided in a sanitary environment. The facility failed to ensure staff assisting 2 of 2 (#0, #5) residents with their meals followed proper sanitation and food handling practices, Staff failed to sanitize their hands after touching their hair, face, clothing and moving about assisting one resident to another.