Colonnades Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Nov 1, 2024

  Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the residents' right to be free from mental abuse/verbal abuse/ and physical abuse by a staff member for four residents, (Resident #5 (R5), Resident #7 (R7) Resident #20 (R20) and Resident #177 (R177)) out of a survey sample of 20 residents, which resulted in psychosocial harm for R20. Immediate jeopardy (IJ) and substandard quality of care in the area of abuse was identified. The findings included: 1. […]

• Immediate jeopardy, patternF689Nov 1, 2024

  Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. […]

• Immediate jeopardy, patternF689Nov 1, 2024

  Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. […]

• No harm, potential for more than minimal, widespreadF835Nov 1, 2024

  Based on resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to effectively administer the facility for residents to maintain their highest practicable well-being, which had the potential to affect all residents residing in the facility. The findings included: For the resident's residing in the facility, the facility administration failed to effectively and efficiently administer the facility to ensure residents were free from and protected from abuse. […]

• No harm, potential for more than minimal, patternF760Nov 1, 2024

  Based on staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from a significant medication error for one resident (Resident #7-R7) in a survey sample of 20 residents. The findings included: For R7, the facility staff failed to administer an antibiotic resulting in a two-day delay in the order being carried out and then resulting in multiple missed doses. On 10/29 and 10/30/24 a clinical record review was conducted of R7's chart. This review revealed R7 had a visit to the hospital on 10/25/24, following a fall where she sustained a laceration to the back of her head which required medical attention. R7 returned to the facility on [DATE]. […]