Colonial Rehabilitation and Nursing, LLC

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours, seven days a week. Specifically, the facility failed to schedule a RN for at least eight consecutive hours on 3/2/26, 3/3/26 and 3/4/26.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#5) of eight residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #5 from verbal abuse by Resident #15.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of three residents reviewed for accident hazards out of 12 sample residents. Specifically, the facility failed to ensure the safe and appropriate use of mechanical lifts when working with Resident #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#18) of four residents reviewed for treatment and care in accordance with professional standards of practice out of 39 sample residents. Resident #18 was admitted on [DATE] for long term care with diagnoses of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness. On 1/3/25 Resident #18 had a wound to his right lateral malleolus (outer ankle) that was healing per the wound physician. On 4/21/25 the wound physician documented the resident's wound had resolved. On 6/9/25 Resident #18 developed a new trauma wound to his right lateral malleolus. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for tone (#4) of four residents reviewed for accidents out of 39 sample residents. Resident #4 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 3/4/25 Resident #4 had an unwitnessed fall in her room and sustained an abrasion to her left knee and a bruise to her forehead. The facility failed to implement a new person-centered fall intervention after the fall. On 3/17/25 Resident #4 sustained another unwitnessed fall in her room where she sustained a right hip fracture that was diagnosed when she was sent to the hospital for evaluation. [...]

Inspectors wroteBased on record review and interviews, the facility failed to take steps to protect four (#67, #39, #36 and #31) of five residents reviewed for abuse out of 39 sample residents. Specifically, the facility failed to protect Resident #67, Resident #39, Resident #36 and Resident #31 from physical abuse by Resident #17.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support the residents' physical, mental and psychosocial well-being were provided for three (#17, #36 and #42) of four residents reviewed for activities out of 39 sample residents. Specifically, the facility failed to to offer and provide personalized activity programs for Resident #17, Resident #36 and Resident #42.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#47, #9 and #42) of five residents were free from chemical restraints were receiving the least restrictive approach for their needs out of 39 sample residents. Specifically, the facility failed to: -Ensure Resident #47 and Resident #9 behavior care plans included resident specific non-pharmacological care approaches;-Document consistent behaviors for Resident #47 and Resident #9 to justify the continued use of psychotropic medications; -Document resident-specific care approaches, to include medication specific target behaviors and person-centered intervention for Resident #47 and Resident #9's psychotropic medications; and,-Ensure gradual dose reductions (GDR) were attempted for Resident #42's psychotropic medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to assistance items for one (#49) of two residents reviewed for ADLs out of 39 sample residents. Specifically, the facility failed to ensure Resident #49, who was dependent on staff for care, received her preferred communication device during ADLs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#14) of four residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure staff provided consistent interventions to Resident #14, who had a pressure ulcer.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (#18) of two residents reviewed for mobility out of 39 sample residents. Specifically, the facility failed to ensure Resident #18's hand splint was applied as ordered to help maintain the resident's limb function and mobility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#7) of three residents reviewed for catheter care out of 39 sample residents. Specifically, the facility failed to:-Use privacy bag for Resident #7's catheter drainage bag;-Ensure Resident #7's catheter was placed appropriately to ensure the urine could flow freely; -Ensure Resident #7's catheter bag was emptied timely; and,-Consistently monitor Resident #7's intake and output per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#22) of two residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure Resident #22's feeding tube was in place prior to administering a bolus feeding per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychological well-being for one (#47) of two residents reviewed for dementia care out of 39 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #47 from wandering into other residents' rooms, shower rooms, the nurses' station and standing over the top of other residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for two (#61 and #42) of five residents reviewed for unnecessary medications out of 39 sample residents. Specifically, the facility failed to ensure Resident #61 and Resident #42 were monitored for hours of sleep for insomnia (difficulty sleeping) medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to ensure the staff followed proper infection control procedures for Resident #7, who was on enhanced barrier precautions (EBP).

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to choose his or her preferred attending physician for four ( #1, #2, #3 and #4) of six residents out of 12 sample residents. Specifically, the facility failed to assist residents to make an informed choice for selecting their attending physician when the facility changed medical provider groups.

Inspectors wroteBased on interview and record review the facility failed to ensure one (#40) out of two residents received adequate supervision to prevent accidents out of 32 sample residents. Specifically the facility failed to ensure -Resident #40's fall interventions were implemented. The resident experienced two falls in one month, one which resulted in a right hip fracture. Additionally, the facility failed to investigate the falls, to determine the root cause.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to ensure food items removed from their original packaging and opened had a dating system.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from resident to resident abuse for two (#48 and #52) of four residents reviewed for physical abuse out of 32 sample residents. Specifically the facility failed to ensure Resident #48 was free from physical abuse from Resident #52. Cross reference F744, dementia care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to offer sufficient fluid intake to sustain hydration and ensure each resident was able to maintain the highest practical level of health and wellbeing for two residents (#21and #25) of 5 reviewed for hydration. Specifically, the facility failed to ensure: -Resident #21 and Resident #25 were provided with sufficient hydration in accordance with the resident's plan of care.

Inspectors wroteBased on record review and interviews, the facility failed to prevent significant medication errors for two (#41 and #49) of five residents reviewed for medication errors out of 32 sample residents. Specifically, the facility failed to ensure: -Resident #41 received prescribed daily doses of Vraylar (antipsychotic) and Trazodone (antidepressant), as ordered by the resident's physician; and -Resident #49 received a prescribed daily dose of Abilify (antipsychotic) and Lialda (anti-inflammatory agent used to treat ulcerative colitis), as ordered by the resident's physician.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a therapeutic diet as prescribed by the physician to two Residents (#69 and #67) of 16 sample residents for a therapeutic diet, out of a total sample of 32 residents. Specifically, the facility failed to follow the physician orders for Resident #69 and Resident #67 to receive a carbohydrate controlled diet (CCD: meals that contain carbohydrate-rich foods in fairly equal amounts to help control the blood sugar levels).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure food items were served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure warm food items were held at the proper temperature to reduce the potential risk of food borne illness; and sanitary conditions were maintained in the kitchen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that three (#15, #57 and #65) out of three residents reviewed for dignity out of 36 sample residents, were treated in a dignified manner Specifically, the facility failed to ensure: -Resident #57 and Resident #65 were informed and/ or offered to be assisted away from the table prior to housekeeping personnel sprayed sanitizing chemical on the tables, while residents were still seated at the dining table; and -Ensure resident #15 wishes were honored around going to bed. -Ensure resident #15 wishes around plugging in motor scooter were honored.

Inspectors wroteBased on observations and interviews the facility failed to provide a clean, comfortable and homelike environment. Specifically, the facility failed: -To provide clean hand towels and wash clothes to the residents, and; -Maintain clean dining room floors.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure two (#67 and #15) of two out of 36 sample residents were without restraints. Specifically, the facility failed to ensure: -Resident #67's legs was not propped up on an electric recliner that resident was not able to remotely control; and -Resident #15 had an assessment that justified the use of a wander guard. Findings Include: I. Facility policy The Restraint Management System policy with a revision date of November 2017 was provided by the life engagement coordinator (LEC) on 10/14/19 at 10:17 a.m. The policy documented in pertinent part that .Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. [...]

Inspectors wroteIII. PICC line A. Professional reference Nursing licensure requirements in Colorado (2019) https://www.nursinglicensure.org/state/nursing-license-colorado.html#lpn (retrieved on 10/15/19). It read in pertinent part; A licensed practical nurse (LPN) who completed an intravenous (IV) training should get transcripts and course descriptions from the training center; the candidate should also secure a competency checklist from a former instructor or registered nurse (RN) supervisor. The LPN license in Colorado does not automatically grant IV authority. An IV certification course for LPNs was required to perform any IV procedures on residents within their scope of practice. B. policy The administration of an intermittent infusion policy revised May 2016 provided by the director of nurses (DON) on 10/15/19 at 2:00 p.m. read in pertinent part; [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure licensed nurses had competencies. Specifically the facility failed ensure the licensed nurses were trained on the crash carts.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication pass observation error rate was 46.15 %, or 12 errors out of 26 opportunities for error.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure: -Resident food was palatable in taste, texture, appearance, and temperature

Inspectors wroteBased on observation, record review and interviews, the facility failed to complete a comprehensive and accurate assessment of functional capacity after a significant change of condition for one (#70) of 36 sample residents. Specifically, the facility failed to comprehensively assess changes of condition in multiple areas of the resident's physical condition.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide assistance for four (#2, and #44) of four residents reviewed for activities of daily living (ADLs) assistance of 36 sample residents. Specifically, the facility failed to: - Ensure Resident #2 received assistance with communicating her needs; and -Ensure Resident #44 received assistance with meals.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#4) of 36 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, the facility failed to provide timely incontinent care to Resident #4

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for one (#60) out of six residents out of 36 sample residents reviewed. Specifically the facility failed to: -Ensure Resident #60 met his hydration needs

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure one (#49) out of one out of 36 sampled residents reviewed for quality of care received treatment and care in accordance with the comprehensive person-centered care plan. Specifically, the facility failed: -To implement person-centered care plan treatment and care resulting in self injurious behaviors of biting and chewing on arms and hands; -To provide preferred activities to the resident; and -To communicate with the resident while providing care.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically, the facility failed to: -Follow proper hand hygiene with glove uses when working between dirty and clean processes; and -Follow proper sanitization of equipment is between resident use.