Colonial Skilled Nursing Facility LLC

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 1, 2024

  Based on observation and interview, the facility failed to prepare and serve food in a sanitary manner affecting all residents who eat their meals in the facility. Findings include: Observations made during the initial tour of the main kitchen at 9:10 am on 01/29/2024, accompanied by the dietary manager. The following was observed: 1) The oven and stove was very dirty with grease and baked on food. (2) The flat top grill is dirty, stained with food and grease. (3) The test strips for determining the PPM for the sanitizing red bucket and the sanitizing sink had a expiration of November 2021. (4) The shelving under the steam table was very dirty with grease and food. […]

• No harm, potential for more than minimal, patternF657May 15, 2025

  Based on interview and record review, the facility failed to ensure interdisciplinary team (IDT) participation and care plan meetings for 5 of 5 residents reviewed, specifically Resident #3, 6, 18, 16, and 11. The findings: 1) The clinical record review indicated that Resident #3 was admitted to the facility on [DATE] and again on 03/25/25, with diagnoses that included progressive neurological conditions. It was noted that the 5-day Minimum Data Set (MDS) assessment was completed on 03/30/25; however, there was no evidence of care plan meetings held to review the care plan with the Interdisciplinary Team (IDT). On 05/15/25 at 10:02 AM, an interview was conducted with the Director of Nursing (DON) regarding the care plan review process with the IDT. […]

• No harm, potential for more than minimal, patternF803May 15, 2025

  Based on observation, interview, review of menus, and policy review, the facility failed to ensure the menu was developed for a mechanical soft diet, affecting 5 of 21 current residents, to include sampled Residents #15, #6, #17, #177, and #16. The findings included: Review of the policy Therapeutic Diets and Texture Modification dated 01/01/25, documented, in part, Policy Purpose: To ensure all residents receive appropriate nutrition that meets their medical, functional, and cultural needs through individualized therapeutic and texture-modified diets as ordered by a physician or registered dietitian. 6. Menu Planning: Menus are developed to accommodate various therapeutic diets and modified textures. […]

• No harm, potential for more than minimal, patternF880May 15, 2025

  Based on policy review, observation, interview, and record review, the facility failed to adhere to infection control practices by failing to update the water management plan to include the appropriate team, failing to maintain linens in clean condition, failing to keep the laundry sorting area clean, and failing to disinfect blood pressure monitoring equipment after use. The findings included: 1) The Infection Prevention and Control Program policy, dated 05/12/25, indicated that a water management program has been established as part of the overall infection prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. […]

• No harm, potential for more than minimal, patternF726Feb 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure competent nursing staff as evidenced by the failure to: 1) Document the antibiotic stop-date for 1 of 1 sampled resident receiving antibiotic therapy (Resident #130); 2) Document medication administration for 5 of 5 sampled residents chosen for unnecessary medications (Residents # 12, #4, #13, #81, and #26); and follow blood pressure parameters for 1 of 5 sampled residents (Resident #4); 3) Ensure resident was educated to the proper technique of inhaler administration for 1 of 6 observed for medication administration (Resident #81); 4) Accurately document the number of medications administered as evidenced by inconsistencies between the January 2024 MAR and the actual number of medications administered for 1… […]