Colonial Gardens Nursing Home

In the surveyor’s words

From the most serious findings on record at Colonial Gardens Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF925Aug 17, 2021

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent and eradicate (destroy) cockroach infestation (presence of an unusually large number of cockroaches [small insect that can carry and spread infectious diseases]) in the facility's kitchen where food was prepared for 92 of 92 residents. The deficient practice resulted in 92 of 92 residents in the facility to have the potential to experience food infection from ingesting food containing toxins from bacteria, and disease transmission from vector-borne (illness that results from infections transmitted to humans by insects such as cockroaches) that can lead to life threating complications and death. […]

• Immediate jeopardy, patternF880Feb 10, 2023

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to address the rashes noted on seven of seven residents (Residents 1, 2, 3, 4, 5, 6, and 7). The facility failed to ensure all seven residents, who were exhibiting symptoms of suspected scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite), were provided with necessary care and treatment, and placed on contact precautions (intended to prevent transmission of infectious agents). On 1/25/2023, the facility identified an additional 36 of 88 residents with rashes. The facility failed to: a. […]

• Immediate jeopardy, isolatedF689Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to: 1. Assess the elopement (to leave unnoticed) risk for one of two sampled residents (Resident 1) who attempted to elope from the facility on 4/30/2024 and 5/23/2024 and was assessed on the Minimum Data Set (MDS, resident assessment and care-screening tool) as having wandering behaviors (when a person leaves a safe area or caregiver, which can be a risk to their safety, also called elopement), per the care plan. 2. […]

• Actual harm, isolatedF689Mar 24, 2023

  Based on interview and record review, the facility failed to provide the required supervision for one of three sampled residents (Resident 2) after two fall incidents. 1. Resident 2 fell on [DATE] (first fall), the facility failed to revise the resident's care plan, failed to reassess the resident's fall risk, ensure the resident's wheelchair alarm was functional, and failed to ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting was held post fall. 2. […]

• Actual harm, isolatedF604Apr 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure four (4) of 10 sampled residents (Residents 84, 36, 345, and 80) were free from physical restraints, by not ensuring: 1. Assessments were completed prior to applying the physical restraints. 2. Adequate monitoring and periodic release of the physical restraints to ensure adequate blood circulation and skin integrity. 3. Development and implementation of care plans addressing the use of physical restraints. 4. […]