Colonial Heights Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Colonial Heights Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF806Jun 17, 2026

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide food that accommodated a resident's food allergies, resulting in harm for one of 35 residents in the survey sample, Resident #5, and failed to provide food that accommodated a resident's food preferences for one of 35 residents in the survey sample, Resident #51. The findings include: 1. For Resident #5 (R5), the facility staff provided fish, a food the resident was allergic to, resulting in the resident's tongue swelling and requiring the use of emergent allergy medications. […]

• Actual harm, isolatedF689Jan 3, 2025

  2. For Resident #27 (R27), the facility staff failed to check placement and function of a wander guard (1) as ordered on multiple dates in October, November and December of 2024. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/20/24, the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section E documented no wandering behaviors. The assessment documented the use of a wander/elopement alarm used daily. The physician orders for R27 documented in part, Wander guard - Check placement, function and skin integrity every shift every shift for elopement. […]

• No harm, potential for more than minimal, widespreadF727Jun 17, 2026

  Based on staff interviews, facility document review and clinical record review, it was determined that the facility staff failed to provide RN (registered nurse) coverage for eight hours per day, seven days a week for two of 30 days reviewed, which had the potential to affect all residents. The findings include:The facility staff failed to provide RN (registered nurse) coverage for eight hours per day, seven days a week for two of 30 days reviewed, May 17, 2026 and May 22, 2026.During the facility task Sufficient and Competent Staffing and review of the 30 days as worked schedule, it was noted that two dates 5/17/26 and 5/22/26 had no RN coverage.On 6/16/26 at approximately 3:00 PM the Regional Director of Clinical Services was asked to provide timecard detail of RN coverage for those… […]

• No harm, potential for more than minimal, widespreadF814Jun 17, 2026

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain the area surrounding the facility's three dumpsters in a sanitary manner.The findings include:On 6/15/26 at 11:20 AM, went on a Kitchen tour with the Food Services ManagerOn 6/15/26 at approximately 11:40 AM, an observation was made on the way out of the building, trash outside of kitchen door a ball of paper, cigarette butts and lime peel. Two of the Three dumpsters-left and middle were filled above top of dumpster with two flaps on both dumpsters open. Right dumpster top closed, is for cardboard boxes. walking up to all Three dumpsters there were pieces of trash and food debris(sausage, eggs, bread, pieces of plastic and cardboard). […]

• No harm, potential for more than minimal, widespreadF725Jan 3, 2025

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain adequate staffing to consistently meet the needs of the residents on three of three facility units. The findings include: Review of the reported quarter four 2024 PBJ staffing data report for the facility documented triggered areas of concern for one star staffing and excessively low weekend staffing. During the dates of the survey private interviews were conducted with cognitively intact residents and resident representatives. […]