Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 67
Capacity: 75
Deficiencies: 1
May 9, 2025
Visit Reason
The inspection was conducted as a biennial survey and complaint investigation for Colonial Healthcare, a Level IV PNMI Residential Care Facility, to assess compliance with regulations governing assisted housing programs.
Findings
The facility was found not in substantial compliance due to failure to ensure medications were administered correctly, specifically one of three resident records reviewed showed incorrect medication dosage administration.
Complaint Details
The finding was confirmed with the Residential Care Director at the time of the survey on 5/9/2025.
Severity Breakdown
Classes II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medication was administered in the correct dose for Resident #2. | Classes II |
Report Facts
Resident records reviewed: 3
Resident #2 medication order date: Mar 25, 2025
Medication administration record date: Apr 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Libby | Administrator | Administrator of Colonial Healthcare, signed the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 75
Deficiencies: 1
May 9, 2025
Visit Reason
The inspection was conducted as a biennial survey combined with complaint investigations to assess compliance with regulations governing Level IV Residential Care Facilities.
Findings
The facility was found not in substantial compliance due to a medication administration error where one resident was given medication at a blood pressure reading below the ordered threshold. This finding was confirmed with the Residential Care Director during the survey.
Complaint Details
The visit included complaint investigations identified by references 2025-AHP-40697 and 2025-AHP-41048, with the medication administration error substantiated during the survey.
Severity Breakdown
Class II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medication was administered in the correct dose for one resident, specifically administering Metoprolol Tartrate despite blood pressure being below the hold threshold. | Class II |
Report Facts
Resident census: 67
Total capacity: 75
Resident records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Libby | Administrator | Named as facility administrator |
| Residential Care Director | Confirmed medication administration finding during survey |
Inspection Report
Capacity: 75
Deficiencies: 0
Dec 16, 2024
Visit Reason
This document is a statement of deficiencies and plan of correction for Colonial Health Care, a Level IV PNMI Residential Care Facility, related to licensing and certification oversight.
Findings
Colonial Health Care is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control, Part of 10-144, Chapter 113.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 75
Deficiencies: 0
Oct 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation identified by case numbers 2024-AHP-38721/38879/38569.
Findings
Colonial Health Care, a Level IV PNMI Residential Care Facility, was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 75
Deficiencies: 0
Oct 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation identified as 2024-AHP-38284/38523 for Colonial Health Care, a Level IV PNMI Residential Care Facility.
Findings
The facility was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control, Part of 10-144, Chapter 113.
Complaint Details
Complaint investigation 2024-AHP-38284/38523 completed with findings of substantial compliance.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 75
Deficiencies: 0
Aug 14, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation identified as 2024-AHP-38166.
Findings
Colonial Health Care, a Level IV PNMI Residential Care Facility, was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 75
Deficiencies: 0
Jul 25, 2024
Visit Reason
The visit was conducted as a complaint investigation identified as 2024-AHP-37740/37823 for Colonial Health Care, a Level IV PNMI Residential Care Facility.
Findings
Colonial Health Care was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control, Part of 10-144, Chapter 113.
Complaint Details
Complaint investigation 2024-AHP-37740/37823 was completed with findings of substantial compliance.
Report Facts
Census: 65
Total Capacity: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaqualine Libby | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Capacity: 65
Deficiencies: 0
Mar 1, 2024
Visit Reason
A complaint investigation was conducted at the facility.
Findings
No deficiencies were found during the complaint investigation review.
Complaint Details
Complaint investigation completed with no deficiencies found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Libby | Administrator | Named as the facility administrator. |
Inspection Report
Complaint Investigation
Capacity: 65
Deficiencies: 0
Feb 1, 2024
Visit Reason
A desk review complaint investigation was completed on 2/1/2024.
Findings
No deficiencies were found during the review.
Complaint Details
Desk review complaint investigation completed with no deficiencies found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Libby | Administrator | Named as administrator of the facility. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 7, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Colonial Health Care, a Level IV PNMI Residential Care Facility, related to licensing and functioning regulations for assisted housing programs.
Findings
Colonial Health Care is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 31, 2023
Visit Reason
The inspection was conducted as a complaint investigation identified as 2023-AHP-34145 for Colonial Health Care, a Level IV PNMI Residential Care Facility.
Findings
Colonial Healthcare is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
Inspection Report
Biennial Survey
Census: 49
Capacity: 65
Deficiencies: 4
May 23, 2023
Visit Reason
The visit was a biennial survey to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for a Level IV PNMI Residential Care Facility.
Findings
The facility was found not in substantial compliance due to deficiencies in employee records, mechanical dishwashing sanitation, lack of locks on bathing facility doors, and water temperatures exceeding the allowed maximum in resident areas.
Severity Breakdown
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Results of annual personnel evaluations were not found in employee records after 2021. | — |
| Dishwasher final rinse temperature did not meet the required minimum of 180°F, with observed temperatures not exceeding 175°F. | — |
| Bathing facility 'west shower room' lacked locks on doors or stalls, compromising resident privacy. | — |
| Water temperatures in resident areas exceeded the maximum allowed 120°F, with measurements of 122°F and 125.5°F recorded. | Class III |
Report Facts
Census: 49
Total Capacity: 65
Dishwasher test cycles: 5
Water temperature: 122
Water temperature: 125.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Libby | Administrator | Confirmed findings during survey and exit conference |
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