Colonial Oaks Living Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF804May 5, 2026

  Based on observations and interviews, the facility failed to ensure food from the facility's kitchen was palatable in flavor as required. Findings:Resident #1 Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/2026 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #1 was cognitively intact. In an interview on 05/03/2026 at 10:05AM, Resident #1 indicated the facility's food was terrible. […]

• No harm, potential for more than minimal, patternF842Feb 25, 2026

  Based on interviews and record reviews, the facility nursing staff failed to document assistance provided with bathing, oral care, and eating for 1 (Resident #1) of 3 residents reviewed for activities of daily living care provided. Findings:Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 12/09/2025 revealed, in part, Resident #1 had a diagnosis of Parkinson's disease (a progressive neurological disorder that affects movement) and required substantial/maximum assistance from staff with bathing, oral hygiene, and eating. Review of Resident #1's care plan revealed, in part, Resident #1 required assistance with Activities of Daily Living and staff were to assist Resident #1 with bathing, hygiene, and eating. […]

• No harm, potential for more than minimal, patternF812Apr 8, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure the kitchen's dishwasher and 3 compartment sink parameters were maintained to correctly sanitize dinnerware. Findings: Observation on 04/08/2025 at 8:10AM revealed after multiple attempts the dishwasher temperature gauge read 90 degrees Fahrenheit ( F). In an interview on 04/08/2025 at 8:11AM, S10Culinary Aide (CA) indicated the dishwasher's water wash temperature was 90 F. S10CA further indicated they were using a sanitizer for the dinnerware. In an interview on 04/08/2025 at 8:12AM, S9Dietary Manager (DM) indicated the dish machine's water temperature was not getting to 150 F as it should. […]

• No harm, potential for more than minimal, patternF689Feb 5, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident's individualized fall prevention interventions were implemented to prevent future falls for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accidents. Findings: Review of the facility's Fall Protocol policy and procedure dated 10/14/2014 revealed, in part, the purpose of the fall protocol was to initiate preventative fall approaches and provide appropriate interventions to prevent falls. […]

• No harm, potential for more than minimal, patternF684Apr 11, 2024

  Based on observations, interviews, and record review the facility failed to ensure an enteral feeding bag (which contains an enteral formula for purpose of supplying nutrients directly into the stomach) was properly labeled to include the date and time of initiation and the rate of infusion. This practice was identified for 1(Resident#1) of 1 (Resident #1) sampled for enteral feeding. Findings: Review of Texas Health and Human Services Evidence-Based Best Practice for Nutritional Support revealed, in part, enteral feeding should include a label with resident's name, date and time of initiation, and the infusion rate. Observation on 04/07/2024 at 10:43 a.m. revealed Resident #31's enteral feeding bag was not labeled with date or time of initiation or the infusion rate of the feeding. […]