Colonial Health & Rehab Center, LLC

In the surveyor’s words

From the most serious findings on record at Colonial Health & Rehab Center, LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 18, 2024

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain residents' highest level of well-being for eight of 35 residents in the survey sample, Residents #5, #138, #139, #63, #32, #48, #16, and #88. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for blood sugar checks and insulin (used to treat diabetes) when the resident was readmitted to the facility on [DATE] at 2:00 p.m. This resulted in harm: on [DATE] at approximately 1:15 a.m., R5's blood sugar was documented as 579 (1). […]

• Actual harm, isolatedF697Sep 18, 2024

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement an effective pain management program for two of 35 residents in the survey sample, Residents #5 and #138. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for pain medications when the resident was readmitted to the facility at 2:00 p.m. on 5/11/24 with two broken femurs (thigh bones). This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. […]

• Actual harm, isolatedF710Sep 18, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the on-call nurse practitioner failed to verify medication orders when the resident was readmitted on [DATE]. This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. Also, the R5's blood sugar was documented as 579 (1), the resident was diagnosed with diabetic ketoacidosis (2), and the resident required an insulin drip (insulin that is intravenously infused). […]

• Actual harm, isolatedF600Jun 23, 2022

  Based on a complaint investigation, a closed medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 4 residents (Resident #4) in the survey sample were free from neglect by failing to obtain an intravenous antibiotic medication upon admission to treat an infection which resulted in rehospitalization . The facility staff neglected to obtain and administer physician ordered intravenous (IV) antibiotic [MEDICATION(S)] every 8 hours (total of 10 misses doses) to treat Resident #4's Left Upper limb [CONDITION(S)], Bacteremia and [CONDITION(S)] Susceptible Staphylococcus Aureus infection which resulted in a rehospitalization on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF684Jun 23, 2022

  Based on a complaint investigation, a closed medical record review, staff interviews and facility document review the facility staff failed to obtain and administer a physician ordered intravenous antibiotic to treat an infection which resulted in a rehospitalization for 1 of 4 residents in the survey sample, Resident #4. The facility staff failed to obtain and administer physician ordered intravenous (IV) antibiotic [MEDICATION(S)] every 8 hours (total of 10 misses doses) to treat Resident #4's Left Upper limb [CONDITION(S)], Bacteremia and [CONDITION(S)] Susceptible Staphylococcus Aureus Infection which resulted in a rehospitalization on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]