Colonial Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF657Feb 25, 2021

  Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the comprehensive care plan for one (1) of three (3) sampled residents (Residents #1). Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/22/2020, the facility assessed the resident to be at risk for elopement and used a Wanderguard device for the resident, which was initiated on 10/21/20. Resident #1 had behaviors of trying to go out the door, packing his/her items and sitting by door; and voicing he/she wanted to leave/go home. In addition, staff had to redirect the resident several times due to going in and out other residents' rooms on 11/18/2020, prior to the elopement. […]

• Immediate jeopardy, isolatedF689Feb 25, 2021

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and monitoring to prevent elopement (exit the facility unsupervised). Resident #1 had a history of wandering and exit seeking behavior, which increased in the evening. On 10/21/2020, the facility assessed the resident required a wanderguard (system used to monitor the resident's location) due to the resident exhibiting behaviors of [CONDITION(S)], delusional behavior, and wandering that placed the resident at significant risk. […]

• Actual harm, isolatedF600Jan 27, 2024

  Based on observation, interviews, record review, and review of the facility's policy, it was determined the facility failed to provide residents with appropriate care and services to ensure residents were free from neglect for one (1) of sixteen (16) sampled residents (Resident #18). Record review revealed the facility admitted Resident #18 on 12/10/2023 and assessed the resident as having an unstageable pressure injury to his/her right heel. However, there were no orders in place for wound care or monitoring until 01/15/2024. […]

• Actual harm, isolatedF655Jan 27, 2024

  Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for two (2) of sixteen (16) sampled residents (Resident #18 and Resident #195). Although the facility admitted Resident #18 on 12/10/2023, and assessed the resident as having a right heel unstageable Deep Tissue Injury (DTI) on that date (with no measurement of the wound), the facility did not develop a Baseline Person-Centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. […]

• Actual harm, isolatedF686Jan 27, 2024

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents reviewed for pressure out of sixteen (16) sampled residents (Resident #18). The facility admitted Resident #18 on 12/10/2023 and assessed the resident on that date as having a right heel unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel pressure injury on admission. […]