Colonial Terrace Care Center

In the surveyor’s words

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

• Actual harm, patternF600Jun 8, 2021

  Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect for one (#3) of four sampled residents who were reviewed for abuse/neglect. Resident #3 was transfered/repositoned in an unsafe [NAME] by staff which resulted in a nondisplaced fracture of the left humerus. There was a delay in treatment and administartation was not notifed in a timely manner when the resident identified to staff the alleged perpetrator The facility identified 41 residents who resided in the facility. […]

• Actual harm, isolatedF689Jun 8, 2021

  Based on interview and record review, it was determined the facility failed to ensure residents were free from accident hazards with transfers/repositioning for one (#3) of three sampled residents who were reviewed for accident hazards. The facility identified 35 residents who required assistance with transfers and/or repositioning. Findings: 1. Resident #3 had diagnoses which included [CONDITION(S)] and [CONDITION(S)] of the non-dominant left side, heart failure, and [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF727May 17, 2023

  Based on record review and interview, the facility failed to ensure an RN worked seven days a week, eight hours a day, for nine of nine days reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The PBJ report for quarter one, documented no RN hours were reported for 11/09/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, 12/03/22, 12/10/22, 12/24/22, and 12/25/22. On 05/17/23 at 2:35 p.m., documentation of RN coverage was requested for the above dates from the BOM. On 05/17/23 at 2:50 p.m., the BOM stated they did not have any RNs who worked on the provided dates. […]

• No harm, potential for more than minimal, patternF580Jun 21, 2024

  Based on record review and interview, the facility failed to ensure resident representatives were notified of change for one (#32) of one sampled resident reviewed for notification of change. The administrator identified 39 residents who resided in the facility. Findings: The undated Notification of Change policy, read in parts, .The nurse will immediately notify the resident .resident representative for the following [list is not all inclusive]: A need to alter treatment significantly [a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment] .Document the notification and record any new orders in the resident's medical record . […]

• No harm, potential for more than minimal, patternF755Jun 21, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents were administered the correct doses of medications ordered by their physician for two (#19 and #93) of six sampled residents reviewed for medication administration. A facility resident roster, dated 06/17/24, documented 39 residents resided at the facility. Findings: An Adverse Consequences and Medication Errors policy, dated 2001, read in part, A medication error is defined as the preparation or administrator of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. […]