Colonial Oaks Skilled Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jun 5, 2025

  Based on record review and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to ensure Resident #331 received needed services and treatment for pain management of a right fractured hip by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. […]

• Immediate jeopardy, patternF697Jun 5, 2025

  Based on record review and interviews the facility failed to provide pain management consistent with professional standards of practice for a resident, following a fractured right hip, for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. Nursing staff failed to ensure severe pain was managed for Resident #331 by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. […]

• Immediate jeopardy, patternF835Jun 5, 2025

  Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to have an effective system in place to obtain and provide pain management for Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. […]

• Actual harm, isolatedF600Dec 14, 2022

  Based on record reviews and interviews the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 (Resident #1) of 6 (Residents #1, #2, #3, #4, #5, #6) sampled residents. The deficient practice resulted in actual harm of Resident #1 on 10/10/2022 when the resident was found on the floor in Hall A bathroom area. Resident #1 reported S3 CNA (Certified Nursing Assistant) threw her out of her wheelchair and beat her up. Resident #1 was assessed by S5 LPN and S7 LPN and found to have injuries including dark red scratches across the front of her neck, a large contusion to back of her head, and blue colored bruising to her left forearm. Resident #1 complained of pain to her right lower back and left forearm near her wrist. […]

• No harm, potential for more than minimal, widespreadF851Apr 23, 2024

  Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required. Findings: Review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 1 2024 (October 1 - December 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the facility's weekend staffing pattern forms for FY Quarter 1 2024 (October 1 - December 31) revealed in part, the facility provided 185.8 hours of direct care on 12/03/2023 and provided 189.6 hours of direct care on 12/10/2023. […]