Colonial Oaks Health Care Center

In the surveyor’s words

From the most serious findings on record at Colonial Oaks Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880May 7, 2021

  A. Based on observation, interview, and record review, the facility failed to ensure masks were worn and handled in accordance with professional standards and hand hygiene was performed as indicated to mitigate the risk of transmission of COVID-19 during 4 of 4 random observations on the Chestnut hallway (green and yellow zones) and Redbud hallway (green zone). B. Based on observation, interview, and record review, the facility failed to ensure shared glucometers were disinfected according to facility policy for 1 of 1 observations of glucometer use on the Hickory hallway. C. […]

• No harm, potential for more than minimal, isolatedF744Aug 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure nonpharmacological interventions were attempted prior to the administration of an as needed (PRN) psychoactive medication for 1 of 2 residents reviewed for dementia care (Resident 6). Finding includes: During an observation on 8/21/23 at 11:50 a.m., Resident 6 sat in her wheelchair in the hall and yelled help repeatedly. She indicated she wanted someone to get her car keys. During an observation on 8/23/23 at 11:32 a.m., the resident sat in her room in her wheelchair and made repeated nonsensical sounds which were followed by utterances of oh, oh, oh repeatedly. During an observation on 8/24/23 at 10:50 a.m., the resident yelled help repeatedly. […]

• No harm, potential for more than minimal, isolatedF600Feb 14, 2023

  Based on interview and record review the facility failed to prevent neglect of 1 of 3 residents reviewed for neglect. (Resident D) Findings include: The clinical record for Resident D was reviewed on 2/14/2023 at 8:33 a.m. Diagnoses included chronic pain syndrome, paraplegia, acute cystitis with hematuria, anemia, hypertension, anxiety disorder, idiopathic peripheral autonomic neuropathy, ileostomy, stage 4 left hip pressure ulcer, stage 4 sacral region pressure ulcer, stage 4 left buttocks pressure ulcer, stage 4 right buttocks pressure ulcer, stage 3 left heel pressure ulcer, and stage 2 right heel pressure ulcer. […]

• No harm, potential for more than minimal, isolatedF623Jun 17, 2022

  Based on record review and interview, the facility failed to provide notification of transfer or discharge to a resident or the resident's representative and failed to provide notification to the Long Term Care Ombudsman for 1 of 5 residents reviewed for hospitalization s (Resident 66). Findings include: Resident 66's clinical record was reviewed on 6/15/22 at 9:12 a.m. Her nurses notes indicated, but was not limited to the following: On 4/27/22 at 9:20 a.m., she had a leave of absence to a hospital for surgery. On 4/28/22 at 8:03 p.m., she returned to the facility by ambulance. On 5/30/22 at 4:45 a.m., she had increased confusion, an order was received to send her to the emergency room . On 6/2/22 at 10:36 p.m., she returned to the facility by ambulance. […]

• No harm, potential for more than minimal, isolatedF758Jun 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents did not receive [CONDITION(S)] medications without indication for use for 1 of 5 residents reviewed for unnecessary medications (Resident 67). Findings include: On 6/14/22 at 2:07 p.m., Resident 67 was observed in bed. On 6/15/22 at 9:31 a.m., she was in bed. During a wound observation, on 6/15/22 at 10:51 a.m., she asked the nurse for a pain pill for pain in her bottom and her shoulder. On 6/15/22 at 1:12 p.m., she was standing up at the side of her bed holding onto her overbed table talking with roommate. On 6/16/22 at 9:51 a.m., she was in bed. On 6/17/22 at 10:56 a.m., she was in bed. Resident 67's clinical record was reviewed on 6/14/22 at 1:59 p.m. […]