Colonial Care Center

In the surveyor’s words

From the most serious findings on record at Colonial Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880May 31, 2022

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for three of 29 residents (Residents 1, 2, and 3) with suspected scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) or suspicious rash by failing to: 1. Ensure Residents 1, 2, and 3 who were exhibiting symptoms of suspected scabies were placed on isolation and ensure the facility protocol for scabies was followed. 2. Conduct an infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents with a suspicious rash in the sub-acute unit. 3. […]

• Immediate jeopardy, isolatedF678Feb 6, 2025

  Based on interview and record review, the facility failed to ensure that a resident with a Full Code status (resident wants all life saving measures in case of life threatening emergencies) and in distress, received Cardiopulmonary Resuscitation (CPR-an emergency procedure to restart a person's heart, chest compressions) immediately, reducing the residents chances of survival and adverse health outcomes for one of 145 residents with Full Code status (Resident 44). The facility failed to: 1.Ensure Registered Nurse (RN) 2 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when Resident 44 had no palpable (rhythmic beat of a blood vessel indicating a heartbeat, that can be felt by touch) heartbeat. […]

• Immediate jeopardy, isolatedF692Feb 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a severe weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 48 residents receiving GT feeding (Resident 188). The facility failed to ensure: 1.The licensed nurses conducted a change of condition (COC) assessment and monitored Resident 188 closely including weekly weights, signs and symptoms of malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and… […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on interview and record review, Licensed Vocational Nurse (LVN) 1 failed to assess the mobility limitations and take precautions before moving one of three sampled residents (Resident 1), who was dependent on staff to roll from the left to the right side. The facility failed to ensure: LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff to roll from the left side to the right and or the assistance of two or more helpers was required for Resident 1 to roll from the left to the right side. This deficient practice resulted in LVN 1 repositioning Resident 1 without assistance and hitting Resident 1's right knee on the resident's bed frame. […]

• Actual harm, isolatedF684Nov 6, 2025

  Based on observation, interviews and record reviews, the facility did not provide timely medical intervention and transferred to a general acute care hospital (GACH) for one of three sampled residents (Resident 1) who experienced a significant change in condition related to unmanaged pain and delayed treatment. The facility failed to: 1. Notify Resident 1's physician promptly after receiving an order for right hip and right femur (the bone of the thigh or upper hind limb, articulating at the hip and the knee) x-ray (images of the inside of the body) result on 10/22/2025 at 1:22 a.m. […]