Colonial Village

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to provide nutritional interventions to prevent Resident (R)25's identified and continued slow weight loss. As a result of the deficient practice, R25 had a significant unplanned weight loss of 13.06 percent (%) within three months. This also placed R25 at risk for malnourishment related complications. Findings Included: [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Five Certified Nurse Aides (CNAs) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 36 residents with one kitchen and two dining rooms with kitchenettes. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses. Findings Included: - On 10/29/24 an inspection of the facility's kitchen was completed. An inspection of the walk-in refrigerator unit revealed an open but undated half-gallon carton of milk and a carton of heavy whipping cream. An inspection of the back hall kitchenette revealed an unlabeled plate of spinach and beef sandwich and an undated bag with dessert pastries. An inspection of the main dining kitchenette drink station revealed an open and undated bottle of whipping cream. [...]

Inspectors wroteThe facility identified a census of 36 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene and disinfecting shared equipment between each resident. These deficient practices placed the residents at risk for complications related to infectious diseases.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide written notification of transfer to Resident (R)32 and/or their representative, with a written notice specifying the location and reason for R32's facility-initiated transfer. This deficient practice placed R32 at risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a copy of the bed hold policy to Resident (R)32 and/or their representative, when R32 was transferred to the hospital. This deficient practice placed R32 at risk for impaired right to return to the facility to the same room.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)7 and R16's pressure-reducing interventions were implemented correctly when their low air-loss mattress pumps were set at an inappropriate weight for each resident. This deficient practice placed all affected residents at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with two residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 36 had a physician-ordered indication for an indwelling catheter and failed to provide adequate catheter care within the standards of care. This deficient practice placed R36 at risk of catheter-related complications and urinary tract infections (UTI).

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure that as-needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 90's PRN psychotropic medications. This placed R90 at risk for unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R)7. This deficient practice placed R7 at risk for delayed services and uncommunicated care needs.

Inspectors wroteThe facility identified a census of 30. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to secure the main dining room kitchenette. This deficient practice placed five cognitively impaired independently mobile residents at risk for potential hazards or preventable accidents. The facility additionally failed to ensure Resident (R)22's Dycem (thin, rubber-like material that helps prevent sliding) was in her chair, as directed by the care plan, to prevent falls. This deficient practice placed R22 at risk for increased falls and injury. Findings Included: -On 06/07/23 at 09:37PM an inspection of the kitchenette after breakfast service revealed no doors to secure kitchenette or potentially hazardous equipment. The kitchenette was left unsecured and unsupervised. [...]

Inspectors wroteThe facility identified a census of 30 residents. The census included 12 residents. Based on observation and interview the facility failed to ensure safe and secure storage of medications when staff failed to securely lock one medication cart when the staff member was away from the cart. This deficient practice placed the facility's five independently mobile, cognitively impaired residents residents at risk accidental ingestion of medication and adverse reaction.

Inspectors wroteThe facility identified a census of 30 residents with one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

Inspectors wroteThe facility identified a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure staff practiced standard infection control practices regarding appropriate hand hygiene and the facility failed to store oxygen tubing, nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and nebulizer mask in a sanitary manner. This placed the affected residents at risk for contagious illness.

Inspectors wroteThe facility identified a census of 30 residents. The sample included 12 residents with one resident reviewed for self-administration of medication. Based on observation, record review, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 85. This deficient practice placed R85 at risk for unnecessary medication side effects and self-administration errors.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22 was free of physical restraints when staff placed R22 in an electric recliner, raised the footrest, then unplugged the recliner despite R22 was unable to manually lower the footrest on her own. This positioning of the footrest and R22's inability to move the footrest created a physical restraint as the footrest impeded R22's freedom of movement and mobility. This deficient practice placed R22 at risk for impaired mobility, rights, and at increased risk for restraint related accidents. Findings Included: [...]

Inspectors wroteThe facility identified a census of 30 residents. The sample included 12 residents with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop person-centered comprehensive care plan for Resident (R) 20 related to his ability to transfer using a transfer bar. This deficient practice placed R20 at risk of injuries related to unmet or uncommunicated needs.

Inspectors wroteThe facility identified a census of 30. The sample included 12 residents with 12 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)27's plan of care was updated to include exercises to prevent a decline in his range of motion (ROM) and functional abilities for self-care. This deficient practice placed R27 at risk for decline in ROM and contractures (abnormal permanent fixation of a joint) due to uncommunicated care needs.

Inspectors wrote- The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, major depressive disorder (major mood disorder), insomnia (difficulty sleeping), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), and dementia (progressive mental disorder characterized by failing memory, confusion). [...]

Inspectors wroteThe facility identified a census of 30. The sample included 12 residents with one reviewed for decreased range of motion (ROM). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)27 received services to prevent a decline in his ROM and functional abilities for self-care. This deficient practice placed R27 at risk for decline in ROM and contractures (abnormal permanent fixation of a joint).

Inspectors wroteThe facility identified a census of 30 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to monitor urine output (an indication of proper fluid intake or the presence of a problem and a common parameter of kidney function) and provide catheter (a tube placed in the bladder to drain urine into a collection bag) care to Resident (R) 8, who had a diagnosis of a neurogenic bladder (urinary condition where there is a lack bladder control due to a brain, spinal cord or nerve problems) and required the use of an indwelling catheter. This placed R8 at risk for infection and urinary catheter complications. The facility further failed to implement individualized toileting plans or attempt a toileting program related to bowel and bladder incontinence for R12. [...]

Inspectors wroteThe facility identified a census of 30 residents. The sample included 12 residents with one resident reviewed for respiratory services. Based on observation, record review, and interviews, the facility failed the facility failed to store oxygen tubing, nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and nebulizer mask in a sanitary manner for Resident (R) 10. This deficient practice placed R10 at increased risk to develop a respiratory infection.

Inspectors wroteThe facility identified a census of 30 resident. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to provide a stop-date for Residents(R)25's as needed (PRN) antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) used as a sleep aid. This deficient practice placed R25 at risk for unnecessary medications and side effects. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), insomnia (difficulty sleeping), restless leg syndrome (a condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), heart failure, and acute kidney disease. [...]

Inspectors wroteThe facility identified a census of 30 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit staffing hour data for all nursing personnel by the required deadline.

Inspectors wroteThe facility reported a census of 37 residents. The facility identified one Resident (R)13, on transmission-based precautions. Based on observation, interview, and record review, the facility failed to ensure the housekeeping staff cleaned a contact precaution room in a sanitary manner to ensure effective/appropriate disposal of the trash in the room and the cleaning cloths in the appropriate receptacle. These failures had the potential for affect all residents in the facility.

Inspectors wroteThe facility reported a census of 37 residents with 12 residents selected for review, including seven residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to thoroughly investigate to determine contributing factors and causes of the falls, and implement appropriate interventions following falls to prevent further falls for Residents (R)4, R7, R10, R12, and R22.

Inspectors wroteThe facility reported a census of 37 residents with 12 selected for review, including two residents reviewed for Activities of Daily Living. Based on observation, interview, and record review, the facility failed to ensure one of the residents who was dependent on staff for personal hygiene, Resident (R)26, received appropriate assistance needed for trimming of his fingernails.

Inspectors wroteThe facility identified a census of 37 residents with 12 selected for review including two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to keep the drainage bag from touching directly on the floor and anchoring the catheter tubing for one of the residents, Resident (7) with a history of urinary tract infections (UTI), creating a risk for developing further UTI's.