Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
A Standard Recertification and an Abbreviated Survey investigating KY00042875 was initiated on 04/09/2025 and concluded on 04/11/2025.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. No deficiencies were issued related to KY00042875.
Report Facts
Sample Size: 12
Supplemental Residents: 0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
Annual inspection survey of Colonial Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 11
Date: Jan 27, 2024
Visit Reason
Routine inspection of Colonial Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care planning, wound care, staffing, infection control, and discharge planning.
Findings
The facility failed to treat residents with dignity, ensure timely meal service, provide access to survey results, inform residents about advance directives, prevent neglect related to wound care, develop timely baseline and revised care plans, provide adequate staffing, ensure effective communication for non-English speaking residents, and maintain infection control precautions.
Deficiencies (11)
F0550: The facility failed to treat residents with dignity by not covering catheter bags for three residents and delayed meal service for one resident by 32 minutes.
F0577: The facility failed to ensure residents could easily view nursing home survey results; the survey binder was not readily accessible and residents were unaware of its location.
F0578: The facility failed to ensure nine residents were informed about advance directives; no documented evidence of providing information or assistance was found.
F0600: The facility neglected one resident by failing to provide timely wound care for a right heel unstageable pressure injury for 36 days, resulting in wound deterioration and lack of pressure relief interventions.
F0655: The facility failed to develop and implement baseline care plans within 48 hours for two residents, including one with a pressure injury and one with a urostomy, lacking necessary interventions and treatment orders.
F0657: The facility failed to revise a resident's care plan to reflect a change in transfer needs from limited assist to total body lift, resulting in lack of updated interventions.
F0660: The facility failed to develop and implement an effective discharge planning process for one resident; no discharge plan was documented upon admission.
F0676: The facility failed to provide an effective communication system for a non-English speaking resident; interpreter services and communication devices were not consistently available or used.
F0686: The facility failed to provide appropriate pressure ulcer care for one resident with an unstageable right heel pressure injury, including lack of timely wound evaluation, treatment orders, pressure relief interventions, and monitoring.
F0725: The facility failed to provide adequate nursing staff to meet resident needs; residents reported delayed call light responses, insufficient weekend staffing, and staff shortages impacting care.
F0880: The facility failed to maintain an effective infection prevention and control program; Enhanced Barrier Precautions were inconsistently implemented and residents with wounds or indwelling devices were not properly protected from infection risks.
Report Facts
Residents on Enhanced Barrier Precautions: 25
Delay in wound treatment orders: 36
Delay in baseline care plan: 16
Delay in baseline care plan: 16
Delay in baseline care plan: 16
Delay in baseline care plan: 16
Delay in baseline care plan: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Completed admission assessment for Resident #18; documented wound but did not measure or photograph |
| Assistant Director of Nursing | ADON | Provided wound care, signed admission assessment for Resident #18, unaware of wound on admission |
| Director of Nursing | DON | Expected wound protocols to be followed; assessed Resident #18's wound; did not update care plan for transfer change |
| Administrator | Administrator | Expected wounds to be assessed and treated; stated facility was adequately staffed |
| Certified Nursing Assistant #2 | CNA | Provided care to Resident #18; unaware of pressure injury or interventions |
| Certified Nursing Assistant #5 | CNA | Provided care to Resident #18; unaware of pressure injury or interventions |
| Certified Nursing Assistant #6 | CNA | Reported staffing shortages and lack of resident care on weekends |
| Certified Nursing Assistant #3 | CNA | Reported working long shifts alone due to staffing shortages |
| Certified Nursing Assistant #10 | CNA | Communicated with Resident #30; stated resident did not speak English but comprehended |
| Minimum Data Set Nurse | MDS Nurse | Documented Resident #18's wound as unstageable; stated baseline care plan should include wound interventions |
| Infection Preventionist | IP | Provided education on Enhanced Barrier Precautions; stated facility had discontinued EBP prior to survey |
Inspection Report
Deficiencies: 4
Date: Jun 13, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, psychotropic medication use, food storage safety, and infection control practices at Colonial Nursing and Rehabilitation Center.
Findings
The facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) for psychotropic drug use for one resident. The facility also failed to limit PRN psychotropic medication use to 14 days without documented rationale for extension. Food products were found stored without proper labeling in the kitchen. Infection control practices during perineal and Foley catheter care were inadequate, including improper glove use and hand hygiene.
Deficiencies (4)
F 0656: The facility failed to develop and implement a person-centered Comprehensive Care Plan for psychotropic drug use for Resident #142 despite orders for PRN Ambien.
F 0758: The facility failed to limit PRN psychotropic medication use to 14 days or document rationale for extension for Resident #142 receiving Ambien for 19 days.
F 0812: The facility failed to store food products in accordance with professional standards, with unlabeled frozen, refrigerated, and dry food items observed in the kitchen.
F 0880: The facility failed to maintain proper infection control during perineal and Foley catheter care for Resident #9, including improper glove use, hand hygiene, and reuse of washcloths.
Report Facts
Days PRN Ambien ordered: 19
PRN Ambien doses in May: 6
PRN Ambien doses in June: 4
Number of sampled residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan development and psychotropic medication monitoring. | |
| MDS Coordinator | Interviewed about responsibility for updating care plans and psychotropic medication oversight. | |
| LPN #2 | Interviewed as assigned nurse responsible for receiving Ambien order and care plan development. | |
| Administrator | Interviewed regarding expectations for care plans, medication use, food labeling, and infection control. | |
| Dietary Director | Interviewed about food labeling practices and policy adherence. | |
| State Registered Nurse Aide (SRNA) #1 | Observed and interviewed regarding improper infection control during perineal and Foley catheter care. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about expectations for infection control and care practices. |
Viewing
Loading inspection reports...
