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, isolatedF689May 29, 2025

  Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place for a cognitively impaired resident who was identified as being at high risk for elopement, exhibited exit seeking behaviors, and voiced a desire to leave the facility did not exit the building for 1 (#156) of 11 (#2, #3, #23,#24, #25, #38, #44, #47, #48, #156 and #157) residents at risk for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation for Resident #156 on 05/16/2025 at 8:15 a.m., when Resident #156, who had a BIMS of 4, was cognitively impaired, and exhibited exit seeking behaviors went out of a bathroom window. Resident #156 then walked to a nearby neighborhood approximately 0.5 miles away. […]

• Actual harm, isolatedF600Nov 24, 2025

  Based on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident physical abuse, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #1, a cognitive resident, experienced psychosocial harm as a result of the physical abuse by staff. This deficient practice resulted in psychosocial harm to Resident #1 on 10/11/2025 at 1:15 p.m., when Resident #1 reported to S2 CNA that S3 CNA entered his room without invitation and intentionally poured water on him in an attempt to stop him from masturbating. Resident #1, who had a BIMS score of 15 (cognitively intact), was tearful and fearful following the physical abuse from S3 CNA. […]

• No harm, potential for more than minimal, patternF692May 29, 2025

  Resident #25 Based on observation, interview, and record review, the facility failed to implement and monitor interventions to maintain proper hydration and nutrition for 2 (Resident #25 and Resident #8) of 2 residents reviewed for nutrition. The facility failed to: 1. Implement and monitor hydration consistent with Resident #25's assessed needs; and 2. Notify the Registered Dietician of Resident #8's change in nutritional needs. Findings: Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Intake and Output, Monitoring Fluids revealed the following in part .4. For residents with a physician's order for fluid encouragement, fluids will be encouraged as per the resident's care plan. 6. The following residents require measurement and documentation of intake and output. A. […]

• No harm, potential for more than minimal, patternF812May 29, 2025

  Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 55 residents who resided in the facility. The facility failed to ensure: 1. Food items in pantry were stored in a sealed container; 2. Opened food items in refrigerator and freezer were labeled with an open date and stored in a sealed container; and 3. Snacks considered potentially hazardous food were stored appropriately. Findings: A review of the facility's undated policy titled, Storage: Freezer revealed in part . Keep all frozen foods tightly wrapped or packaged to prevent freezer burn . […]

• No harm, potential for more than minimal, patternF880May 29, 2025

  Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to effect the 55 residents who resided in the facility. The facility failed to: 1. Ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #19) of 1 residents reviewed for infection control; 2. Ensure the facility laundry department was free of lint and dust; and 3. […]