Colonial Rehabilitation and Nursing, LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Nov 23, 2021

  Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. This had the potential to affect all of the residents residing in the facility, as the facility experienced a kitchen fire in the facility's only kitchen. Record review and interviews revealed the facility experienced a fire in the kitchen on 11/7/21, kitchen staff did not follow the facility policy and procedure for a kitchen fire, and instead attempted to extinguish the fire by throwing salt and flour onto the fire. Attempts to smother the fire were unsuccessful, and staff attempted to extinguish the fire with a fire extinguisher, but used the incorrect fire extinguisher. […]

• Actual harm, isolatedF684Jul 24, 2025

  Based on observations, record review and interviews, the facility failed to ensure one (#18) of four residents reviewed for treatment and care in accordance with professional standards of practice out of 39 sample residents. Resident #18 was admitted on [DATE] for long term care with diagnoses of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness.On 1/3/25 Resident #18 had a wound to his right lateral malleolus (outer ankle) that was healing per the wound physician. […]

• Actual harm, isolatedF689Jul 24, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for tone (#4) of four residents reviewed for accidents out of 39 sample residents.Resident #4 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 3/4/25 Resident #4 had an unwitnessed fall in her room and sustained an abrasion to her left knee and a bruise to her forehead. The facility failed to implement a new person-centered fall intervention after the fall. On 3/17/25 Resident #4 sustained another unwitnessed fall in her room where she sustained a right hip fracture that was diagnosed when she was sent to the hospital for evaluation. […]

• Actual harm, isolatedF689Aug 31, 2023

  Based on interview and record review the facility failed to ensure one (#40) out of two residents received adequate supervision to prevent accidents out of 32 sample residents. Specifically the facility failed to ensure -Resident #40's fall interventions were implemented. The resident experienced two falls in one month, one which resulted in a right hip fracture. Additionally, the facility failed to investigate the falls, to determine the root cause. Findings include: I. Facility policy and procedure The Fall Management policy dated 3/10/23 was provided by the nursing home administrator (NHA) on 8/30/23 at 4:56 p.m. It read in pertinent part. […]

• Actual harm, isolatedF600Mar 17, 2022

  Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from neglect and abuse for two (#4 and #8) of four out of 10 sample residents. Resident #4 was dependent on staff for most activities of daily living and transferred with a mechanical Hoyer (mechanical) lift by staff according to their Kardex (computerized overview of each resident's care summary information) and comprehensive plan of care. Resident #4 was transferred on 2/4/22 by a nurse and certified nurse aide using a gait belt, which resulted in a fall with a right femur fracture and associated pain. The facility neglected to transfer Resident #4 according to her plan of care. Resident #8, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]