Colonnades Health Care Center

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the residents' right to be free from mental abuse/verbal abuse/ and physical abuse by a staff member for four residents, (Resident #5 (R5), Resident #7 (R7) Resident #20 (R20) and Resident #177 (R177)) out of a survey sample of 20 residents, which resulted in psychosocial harm for R20. Immediate jeopardy (IJ) and substandard quality of care in the area of abuse was identified.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated.

Inspectors wroteBased on resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to effectively administer the facility for residents to maintain their highest practicable well-being, which had the potential to affect all residents residing in the facility.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from a significant medication error for one resident (Resident #7-R7) in a survey sample of 20 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were securely stored in 1 of 2 medication carts and for 1 resident (resident #128) in a survey sample of 20 residents. The facility staff also failed to ensure that expired medications were not available for use in 1 of 1 medication rooms.

Inspectors wrote2. Four food bins containing rice, flour, sugar, and bread crumbs were labeled as expired and were accessible for distribution in the main kitchen.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure that the facility assessment involved the appropriate participants, which had the potential to affect all operations and residents within the facility.

Inspectors wrote3. For R12, who had multiple falls and sustained a significant head injury, the facility failed to maintain a complete and accurate clinical record to include the details of the fall and the facility's response. On 10/29/24 at 11:03 a.m., during an interview with R12 and his spouse, the spouse reported, He had several falls here, which resulted in a head injury. The first one they called me, he hit his head badly and was bleeding and had to have some surgery on his brain. On the evening of 10/30/24, during a clinical record review, the following was noted. R12 had a fall on 6/10/24. The Fall Progress Note read, Fall was unwitnessed in residents room [ROOM NUMBER]/10/2024 8:00 PM. Residents description of event and how they were feeling: Guest stated that he was going to bed. He stated that he was ok before he fell .No injury noted at time of fall. [...]

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer COVID immunizations, to 4 of 5 residents (resident #7-R7, resident #17-R17, resident #76- R76 and Resident #20-R20) sampled for immunizations and failed to have evidence of having provided staff education regarding COVID immunizations for 3 (licensed practical nurse #1- LPN #1, certified nursing assistant #6- CNA #6, and other employee #5- OE#5) of 3 staff sampled.

Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to provide as part of their Quality Assurance and Performance Improvement (QAPI) program mandatory training for five employees (certified nursing assistants- CNA #1, #4 and #5, licensed practical nurse LPN #4, and registered nurse RN #2) in a sample of five staff members reviewed for educational requirements.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to respond timely to a clinical record request for 1 resident of 20 residents, resident #26 (R26).

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) policy for abuse and failed to implement abuse policy regarding an allegation of abuse and injury of unknown origin for one of 20 residents (Resident #7). The Findings Include: 1. The facility did not communicate or monitor feedback of allegations of abuse during QAPI meetings as directed in the QAPI policy. Review of facility reported incidents indicated that the facility reported an allegation of abuse between a staff member and two residents on 10/2/24. Review of the facility QAPI policy read in part 4. The SNA/designee [skilled nursing administrator] will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include. but is not limited to: b. [...]

Inspectors wroteFor Resident #7 (R7) who made an allegation of abuse/mistreatment, the facility staff failed to report the abuse allegation to the required agencies timely. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. [...]

Inspectors wroteBased on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to complete a thorough investigation for an allegation of abuse for three residents, Resident #5 (R5), Resident #20 (R20), and Resident #177 (R177), in a survey sample of 20 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to adequately develop a comprehensive care plan to address the behavioral health care needs for one resident (Resident #7 - R7), in a survey sample of 20 residents.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #102-R102) in a survey sample of nine residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for two of twenty residents in the survey sample (Residents #14 and #26).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement non-pharmacological interventions for pain for one of twenty residents in the survey sample (Residents #14, R14).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure appropriate dementia care with individualized interventions was in place for one resident (Resident #7 - R7), in a survey sample of 20 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to respond to a medication regime review and recommendations from the pharmacy for 1 resident (Resident #11-R11) in a survey sample of 20 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a gradual dose reduction was performed for one resident (Resident #11- R11), failed to ensure one resident (Resident #7- R7) was free from unnecessary psychotropic medications, and failed to document assessment and monitoring of psychotropic medications effect on two residents (Resident #14-R14 and Resident #7-R7) in a survey sample of 20 residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to provide physician ordered rehab therapy services to three residents in a survey sample of nine residents.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store, prepare, and serve food in a sanitary manner from the main kitchen.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of thirteen residents in the survey sample (Resident #10).

Inspectors wroteBased on a medication pass observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately label a medication for one of thirteen residents in the survey sample (Resident #18).

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to ensure the resident's comprehensive care plan was reviewed and revised in a timely manner. Resident # 2's care plan for the use of Trazodone was not updated to reflect the current dosage.