Colonial Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Oct 29, 2021

  Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to not monitoring to make sure Agency Nursing staff were being tested for COVID-19 per the county positivity rate and tested for COVID-19 before and after the facility's outbreak started. The facility was unaware of any testing results of the Agency Staff who had been tested prior and after the outbreak occurred. The facility also failed to notify the Agency staff who worked in the facility prior to the outbreak and the Staffing Agency of the outbreak, which places the Agency staff, the facility and other facilities where the staff work at risk. […]

• Immediate jeopardy, isolatedF887Oct 29, 2021

  Based on record review and interview, the facility failed to ensure the COVID-19 vaccination was offered to all residents of the facility, related to 2 of 40 residents who were not offered the COVID-19 vaccine after admission. (Residents D and E) Both residents have now tested positive for COVID-19. Resident D had the first positive COVID-19 test on 10/17/21 after presenting with a non-productive cough with diminished lung sounds and was transferred to the emergency room for [CONDITION(S)]. Resident E tested positive on 10/18/21. There are now 35 COVID-19 positive residents, of which 6 have been hospitalized , with 3 of those 6 residents remaining in the hospital, and 13 COVID-19 positive staff in the facility. […]

• Actual harm, isolatedF686Jan 10, 2022

  Based on observation, record review, and interview, the facility failed to ensure pressure ulcer assessments were completed at least weekly to determine the healing status of the pressure ulcers. Two of the pressure ulcers deteriorated, a surgical debridement was completed, and new treatment orders were received for the deterioration of the pressure ulcers when assessed by the Wound Physician, for 2 of 3 residents reviewed for pressure ulcers. (Residents C & D) Findings include: 1) During an observation on 1/10/22 at 10:09 a.m. with RN 1, Resident C was lying in bed with her head of the bed elevated. There was a heel protector boot on the right heel. RN 1 indicated the facility Wound Nurse works part time and the Wound Physician consulted on the pressure ulcers weekly. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2025

  Based on observation and interview, the facility failed to ensure a sanitary kitchen related to testing the dishwasher sanitation level with faulty test strips in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect the 26 of 29 residents in the facility who received food from the kitchen. Finding includes: During the initial kitchen tour on 5/27/25 at 9:10 a.m. with the Dietary Food Manager (DFM), the dishwasher was observed and noted to be a low temperature, chemical system. The DFM obtained a testing strip, dipped it into the dishwasher water and compared it to the results on the side of the testing strip container. The strip did not have a readily discernable color change. He indicated they always used those strips and was unsure why they were not changing. […]

• No harm, potential for more than minimal, patternF912Jun 2, 2025

  Based on observation, record review, and interview, the facility failed to provide at least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208) Findings include: 1. The floor area of the following single resident room measured: a. room [ROOM NUMBER] - 1 resident, 96.2 SQ FT. NF. 2. The floor areas of the following multiple resident rooms measured: a. room [ROOM NUMBER] - 0 residents, 150.3 SQ FT, 75.2 SQ FT per bed. NF. b. room [ROOM NUMBER] - 1 resident, 145.0 SQ FT, 72.5 SQ FT per bed. NF. c. room [ROOM NUMBER] - 1 resident, 149.0 SQ FT, 74.5 SQ FT per bed. NF. d. […]