Signature Healthcare at Colonial Rehab & Wellness

In the surveyor’s words

From the most serious findings on record at Signature Healthcare at Colonial Rehab & Wellness, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 11, 2024

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents were assessed to determine their capacity to consent or were free from sexual abuse for three of 24 sampled (Residents (R) 2, R33, and R34). Review of facility documentation of multiple incidents and sexual abuse allegations involving R63 revealed the following: 1. On 02/22/2022, staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to the monitoring that occurred after the event. 2. […]

• Immediate jeopardy, patternF656Jul 11, 2024

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its staff developed and implemented the resident's care plan with interventions to address inappropriate sexual behavior and failed to ensure the residents were assessed and care planned for the ability to consent to sexual activity for four of 24 sampled residents (Residents (R) 63, R2, R33, and R34). On 02/22/2022, Resident (R) 63 was observed by staff to have kissed R2. The facility failed to develop R63's comprehensive care plan to address the inappropriate behavior. Then approximately 6 months later, on 08/14/2022, R63 kissed R2 again, after R2 asked for a kiss. […]

• Immediate jeopardy, isolatedF760Jul 11, 2024

  Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of any significant medication errors for one of seven sampled residents (Residents (R)58). On 05/03/2022, R58 developed increased altered mental status and was sent to the emergency room (ER) for evaluation. During assessment of R58 at the ER, the ER nurse discovered a 75 microgram (mcg) fentanyl patch (narcotic medication used to treat severe pain) on the resident's left upper arm/shoulder. However, review of the facility's information for R58 revealed no documentation noting fentanyl as one of R58's medications. Review of R2's (R58's roommate) orders revealed that resident had an active order for a 75 mcg fentanyl patch. […]

• No harm, potential for more than minimal, patternF804May 14, 2021

  Based on observation, interview and record review, it was determined the facility failed to ensure food was served at an appetizing temperature. Resident interviews and review of Resident Council Meeting minutes revealed resident complaints of cold food. Observation of the tray line on 05/11/2021 revealed the facility was not using the pellet warmer (part of the plate warming system to keep food warm). A test tray was obtained on 05/11/2021, and the mixed greens were cool and not at an appetizing temperature. The findings include: Review of facility policy titled Food Temperatures dated 3/19/2021 revealed foods should be served at proper temperatures to insure food safety and palatability. […]

• No harm, potential for more than minimal, isolatedF880Jul 11, 2024

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect one (1) out of ten (10) sampled Residents (R), R43. Observation revealed R43's room door had a sign posted noting the resident was on Enhanced Barrier Precautions (EBP). […]