Colonial Pines Healthcare Center

Inspectors wroteBased on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 4 of 4 residents (Residents #5, #6, #17, and #35) reviewed for medical records. The facility failed to ensure Resident #5, Resident #6, Resident #17 and Resident #35's medical records were accurate when staff did not document meal intake for evening meal for dates of January 1, 2026 thru January 20, 2026. This deficient practice could place residents at risk of improper care and monitoring due to inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 dining room reviewed for pest control. The facility failed to ensure the dining room remained free from roaches on 01/19/2026, during the lunch meal, when observed crawling on the floor. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and homelike environment for 1 of 8 (Resident #41 residents reviewed for resident rights. The facility failed to ensure Resident #41 had a wheelchair that was not soiled with old food particles on 01/19/2026 and 01/20/2026. This failure could place residents at risk infections and dignity issues.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly, once every three months, using the quarterly review instrument specified by the state and approved by CMS for 1 of 12 residents (Resident # 41) reviewed for quarterly assessments. The facility failed to ensure Residents # 41 had a quarterly MDS assessment completed within three months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on observations, interviews, and record review , the facility failed to develop a person-centered comprehensive care plan to address medical needs for 1 of 12 residents (Resident #41) reviewed for comprehensive care plans. The facility failed to ensure Resident #41's comprehensive care plan was revised to reflect current transfer status of requiring a mechanical lift, hospice services, swallowing difficulties that required an altered diet and a contracture with mobility limitations. This failure could place residents at increased risk of falls, injuries, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review , the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 4 (Resident #41) residents reviewed for mobility services. The facility failed to implement interventions to prevent further decline of Resident #41's contracture to her left hand and lower extremities on 01/19/2026 and 01/20/2026. This could affect residents with contractures and mobility limitations and could result in a decrease in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 4 residents reviewed for quality of care. (Resident #41)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #41. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, 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 for 1 of 4 residents (Resident #26) and 2 of 5 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed EBP for Resident #26 when providing care on 1/19/2026. This failure could place residents at risk of exposure to infectious diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 4 hallways, (hallway 200 and 400), 2 resident rooms (Resident #33 and Resident #15 rooms) and two of two dining areas (main and locked unit dining areas) reviewed for pest control. The facility failed to ensure hallways, resident rooms and dining rooms were free of flies. This failure could place residents at risk of a diminished quality of life due to an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication storage refrigerators reviewed for temperature controls and storage. The facility failed to log and monitor medication refrigerator temperatures for AM and PM as required per facility policy (24-hour periods of time) on 10/02/24 and 10/03/24 for medication storage. The facility failed to log and monitor temperatures twice daily, as required per facility policy, for the month of October 2024 (10/08/24, 10/21/24 and 10/22/24 were the only days logged for the required notations of twice daily medication refrigerator temperature checks for vaccine storage). This failure could place residents at risk of harm by not maintaining proper controlled temperatures for medications, vaccines, and biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 (Residents #4, Resident #13, and Resident #22) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #4, Resident #13 and Resident #22. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms (400 hall Dining Room), 1 of 4 halls (400 hall) and 1 of 6 (Resident #33) residents reviewed for environment. The facility failed to ensure that the 400-hall dining room and floors and walls were clean and maintained in good repair on 10/27/24. The facility failed to ensure the 400 hall walls and floors were maintained in good repair on 10/27/24. The facility failed to ensure Resident #33's box fan was free of dust and debris on 10/27/24. These failures could affect residents and the staff by placing them at risk for diminished quality of life and injury due to lack of a sanitary and well-kept environment.

Inspectors wroteBased on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 out of 8 dietary staff. The facility did not ensure Dietary Aide H had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerator were not kept past their expiration dates. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. One of six gas stove burners (right back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 1 facility . The facility failed to ensure the staff were smoking in the designated smoking area and disposing of smoking materials properly on 10/27/24. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 2 Residents (Resident # 3) observed for care in that: The facility failed to ensure Resident #3's urinary drainage bag had a privacy cover on 10/22/2024. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 Resident's (Resident #3) reviewed for catheter and incontinence care. 1. The facility failed to ensure LVN A maintained the urine catheter drainage bag below Resident #3's bladder on 10/22/2024. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: The facility failed to ensure opened items in the dry storage were labeled and dated correctly. The facility failed to ensure all food items were discarded by the expiration date. The facility failed to ensure there was soap at the handwashing sink. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, AND CNA H) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, and CNA H. This failure could place staff and residents at risk for not being aware of facility programs, implementation and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 11 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 16 residents (Resident #6) reviewed for resident rights. The facility failed to treat Resident #6 with respect and dignity when she had to ask staff where her food was three times while the other residents seated with her in the dining room were already eating. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #43) reviewed for notification of changes in that: The facility did not notify Resident #43's physician (Physician M) for a significant change in weekly weight indicating a gain of 5-pound gain or greater as ordered (weight gain of 59.1 pounds.) This deficient practice could place residents at risk of not having their physician notified of changes resulting in a delay in continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #259) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #259 addressing oxygen use. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was revised to reflected current orders for monitoring weekly weights and reporting greater than 5-pound weight gain. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 of 8 residents (Resident #259) reviewed for respiratory care. The facility failed to ensure Resident #259 had an order for oxygen therapy and the correct liter flow was administered to the resident. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room reviewed for pharmacy services. The facility failed to properly date Tubersol Purified Protein Derivative (Mantoux Tuberculosis skin testing solution) in the medication storage refrigerator with an open date. The facility failed to remove 2 vials of Flucelvax from the medication storage room refrigerator that had expired on 06/30/2023. The facility failed to monitor and log the temperatures of the medication storage refrigerator twice daily as indicated by policy. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control prevention and practices for medication administration of eye drops by 1 of 4 staff reviewed for infection control. (MA F) * The facility failed to ensure MA F washed her hands, gloved, and followed policy for administration of eye drops. This failure could place residents at risk of bacterial and viral infections or other diseases from pathogens contracted through contamination of mucosa.