Inspection Report Summary
The most recent inspection on June 30, 2025, found Colonial Nursing Home generally in compliance but noted a deficiency related to bedroom size requirements, which was covered by an approved continuing waiver. Earlier inspections showed a pattern of deficiencies involving resident care documentation, infection control, environmental maintenance, and life safety code compliance, particularly issues with building construction type and stairway enclosures. Complaint investigations included several substantiated cases related to inadequate care, medication management, and infection control, though many complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows ongoing challenges with physical environment and care process issues, with some recent improvement in compliance but persistent concerns in certain areas.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
371% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Deficiencies: 1
Jun 30, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey of Colonial Nursing Home.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 based on the paper compliance review. However, a deficiency was noted regarding bedroom size requirements, though a continuing annual waiver was approved.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Bedrooms did not meet the requirement of at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms. | SS=E |
Inspection Report
Annual Inspection
Census: 29
Capacity: 29
Deficiencies: 10
Jun 2, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00458256.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of medication holds, incomplete comprehensive care plans for wounds, inadequate assessment of eye conditions, lack of treatment orders for pressure ulcers, missing fluid restriction orders and monitoring, improper oxygen administration, unsanitary kitchen conditions, improper disposal of lancets, and insufficient resident room sizes. Corrective actions and systemic changes were planned for all deficiencies.
Complaint Details
Complaint IN00458256 was investigated during this visit with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure the resident's physician was notified of medication being held for 1 of 5 residents reviewed for unnecessary medications (Resident 183). | SS=D |
| Failed to ensure a comprehensive care plan was implemented for a resident with a diabetic foot ulcer for 1 of 12 resident care plans reviewed (Resident 13). | SS=D |
| Failed to ensure a resident with a reddened sclera was assessed and monitored for 1 of 2 residents reviewed for vision/hearing services (Resident 20). | SS=D |
| Failed to ensure a resident with pressure ulcers received necessary treatment and services related to not obtaining treatment orders for a wound vac for 1 of 4 residents reviewed (Resident 183). | SS=D |
| Failed to ensure there were orders and/or monitoring completed for a resident on a fluid restriction (Resident 183). | SS=D |
| Failed to ensure a resident received necessary care and treatment related to oxygen administration for 1 of 1 resident reviewed (Resident 9). | SS=D |
| Failed to ensure a sanitary kitchen related to testing the dishwasher sanitation level with faulty test strips in 1 of 1 kitchens observed (Main Kitchen). | SS=F |
| Failed to ensure infection control practices were in place related to disposal of used lancets into the garbage can instead of sharps container for 1 of 1 glucometer testing observed (Resident 183, RN 1). | SS=D |
| Failed to provide at least 80 square feet per resident in multiple resident rooms and 100 square feet in single occupancy rooms in 8 of 30 resident rooms. | SS=E |
| Failed to maintain a sanitary, safe, and homelike environment related to dirty kitchen walls and floors in the kitchen (Main Kitchen). | SS=D |
Report Facts
Census: 29
Total Capacity: 29
Inspection Dates: 5
Rooms with deficient square footage: 8
Wound size: 9.8
Wound size: 5.5
Wound size: 1.7
Dishwasher sanitation level: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed report and involved in interview |
| RN 1 | Nurse involved in medication and wound care deficiencies and improper lancet disposal | |
| Director of Nursing | Director of Nursing | Provided interviews and information on multiple deficiencies including medication holds, care plans, eye assessments, oxygen administration, and lancet disposal |
| Dietary Food Manager | Dietary Food Manager | Observed dishwasher sanitation issues and kitchen cleanliness |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 8, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00454373 completed on March 18, 2025.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Investigation of Complaint IN00454373 completed on March 18, 2025; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Mar 18, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454373, which included federal/state deficiencies related to the allegations cited at F584, F677, and F921, along with unrelated deficiencies.
Findings
The facility was found deficient in maintaining a safe, clean, comfortable, and homelike environment, providing adequate ADL care for dependent residents, ensuring proper infection prevention and control including PPE use and hand hygiene, and maintaining a clean and functional environment with necessary repairs.
Complaint Details
Complaint IN00454373 was investigated with federal/state deficiencies cited at F584, F677, and F921. The complaint involved issues related to cleanliness, ADL care, infection control, and environmental maintenance.
Severity Breakdown
Level D: 2
Level E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure residents had a clean and homelike environment related to soiled bed linens for 2 of 8 residents reviewed. | Level D |
| Failed to ensure residents who were dependent on staff received incontinence care for 2 of 7 residents reviewed for activities of daily living. | Level D |
| Failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to residents in Enhanced Barrier Precautions and failed to ensure hand hygiene and proper use of personal care items. | Level E |
| Failed to ensure the residents' environment was clean and in good repair related to scraped paint, nicks and gouges on the walls, dried feeding on feeding poles and equipment, debris and trash on floors, a dirty floor mat, and a stool with a cracked vinyl seat. | Level E |
Report Facts
Census: 27
Residents reviewed for clean environment: 8
Residents reviewed for ADL care: 7
Residents reviewed for EBP: 2
Rooms audited for environmental issues: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed the report |
| Agency CNA 1 | Failed to use PPE correctly and hand hygiene; used personal care wipes on multiple residents | |
| Agency CNA 2 | Provided incontinence care with soiled linens and failed to check bedding | |
| Agency CNA 5 | Failed to use PPE correctly initially during care | |
| RN 1 | Observed providing care and acknowledged issues with soiled linens | |
| LPN 4 | Acknowledged saturated briefs and urine odor during care | |
| Director of Maintenance/Housekeeping | Acknowledged environmental deficiencies and cleaning issues | |
| Housekeeper 6 | Indicated rooms had been cleaned | |
| Central Supply Clerk | Provided information about cleansing wipes availability |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446594.
Findings
No deficiencies related to the allegations in Complaint IN00446594 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446594 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 31
Medicare residents: 2
Medicaid residents: 19
Other payor residents: 10
Inspection Report
Follow-Up
Census: 30
Capacity: 55
Deficiencies: 2
Oct 22, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey originally conducted on 09/18/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and achieved a passing score on the Fire Safety Evaluation System (FSES) survey. However, deficiencies were noted related to building construction type and stairway enclosures, though these were obviated by the passing FSES score.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility was not an acceptable type of construction as required by NFPA 101 - 2012 edition and NFPA 220 - 2012 edition; the building was Type V (000) and two stories, which is not acceptable for a two-story existing healthcare building. | — |
| Failed to provide and maintain exit stairs and exit stair enclosures in accordance with NFPA 101 - 2012 edition; specific issues included the exit stair by room 201 not enclosed in fire rated construction, metal open grate stair treads with gaps, lack of intermittent landing exceeding allowable distance, and stair width less than required minimum. | SS=E |
Report Facts
Certified beds: 55
Census: 30
Number of risers: 24
Maximum allowable distance between landings (feet): 12
Actual distance between landings (feet): 15
Required minimum stair width (inches): 36
Actual stair width (inches): 30
Inspection Report
Annual Inspection
Census: 33
Capacity: 55
Deficiencies: 9
Sep 18, 2024
Visit Reason
An Emergency Preparedness Survey, Life Safety Code Recertification, and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal and state regulations on September 18, 2024.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and Electrical Systems maintenance. Deficiencies included failure to implement emergency power system testing, unacceptable building construction type, inadequate stairway enclosures, sprinkler system maintenance issues, incomplete elevator firefighter recall testing, lack of annual fire door inspections, incomplete electrical receptacle testing, incomplete generator testing documentation, and improper use of power strips for high current equipment.
Severity Breakdown
SS=F: 6
SS=E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to implement emergency power system testing requirements; generator lacked monthly load and weekly visual testing. | SS=F |
| Facility building construction was Type V (000), which is not acceptable for a two-story existing healthcare building. | SS=F |
| Failed to provide and maintain exit stairs and stair enclosures in accordance with NFPA 101; stair by room 201 was not enclosed in fire rated construction and had other code violations. | SS=E |
| Failed to ensure sprinkler heads were free of paint and foreign materials as required by NFPA 25. | SS=E |
| Failed to maintain monthly testing documentation for elevator firefighter recall; missing records for 8 of 12 months. | SS=E |
| Failed to ensure annual inspection and testing of 7 fire door assemblies were completed and documented. | SS=F |
| Failed to ensure non-hospital grade electrical receptacles in 29 resident rooms were tested annually; last documentation dated August 2023. | SS=F |
| Failed to maintain complete written record of monthly generator load testing for 7 of 12 months and weekly inspection for 4 of 52 weeks. | SS=F |
| Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with high current draw. | SS=E |
Report Facts
Certified beds: 55
Census: 33
Deficiency count: 9
Missing elevator firefighter recall testing months: 8
Missing generator weekly inspections: 4
Resident rooms with non-hospital grade receptacles: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and interviews |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 7
Aug 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00433696, IN00435416, IN00438185, and IN00440056.
Findings
The facility was found deficient in multiple areas including failure to implement activities for a cognitively impaired resident, inadequate wound assessment and monitoring, failure to follow occupational therapy recommendations, incomplete catheter care and urinary output documentation, improper PICC line flushing, incorrect oxygen flow rate, and insufficient bedroom square footage per resident in multiple rooms.
Complaint Details
This survey included investigation of Complaints IN00433696 and IN00440056 which resulted in federal/state deficiencies related to catheter care and urinary output documentation. Complaints IN00435416 and IN00438185 had no deficiencies cited.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure activities were implemented for a cognitively impaired dependent resident. | SS=D |
| Failed to ensure a resident's wounds were assessed and monitored. | SS=D |
| Failed to follow up on an Occupational Therapy recommendation for a resting hand splint. | SS=D |
| Failed to ensure catheter care was completed and urinary output was recorded for a resident with an indwelling catheter. | SS=D |
| Failed to care for a PICC line in accordance with professional standards related to flushing the PICC line. | SS=D |
| Failed to ensure a resident received necessary care related to incorrect oxygen flow rate. | SS=D |
| Failed to provide at least 80 square feet per resident in multiple resident rooms and 100 square feet in single occupancy rooms. | SS=E |
Report Facts
Census: 31
Rooms with square footage below standard: 8
PICC flush volume: 10
Oxygen flow rate: 3
Observation dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed report and identified as facility representative |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 23, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Complaints IN00433696 and IN00440056 completed on August 23, 2024.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review to the Recertification and State Licensure survey and complaint investigation.
Complaint Details
Investigation of Complaints IN00433696 and IN00440056 was included in the review.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of complaints IN00428577 completed on April 15, 2024.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of complaints IN00428577 completed on April 15, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 1
Apr 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428577 regarding federal and state deficiencies related to resident records and identifiable information.
Findings
The facility failed to ensure a resident's medical record was complete and accurate related to incontinence care logs for 1 of 3 residents reviewed. Documentation was incomplete for Resident B, who required incontinence care, with missing entries on several days.
Complaint Details
Complaint IN00428577 was substantiated with federal/state deficiencies cited at F842 related to resident records and identifiable information.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's medical record was complete and accurate related to incontinence care logs for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 35
Total Capacity: 35
Medicaid Census: 25
Other Payor Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed the report and involved in administrative oversight |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Jan 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423561.
Findings
No deficiencies related to the allegations in Complaint IN00423561 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00423561 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 31
Total Capacity: 31
Payor Type Census: 1
Payor Type Census: 22
Payor Type Census: 8
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Oct 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418573.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418573 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 4
Medicaid census: 25
Other payor census: 6
Inspection Report
Follow-Up
Census: 36
Capacity: 55
Deficiencies: 0
Sep 8, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/20/2023 by the Indiana Department of Health.
Findings
At this Emergency Preparedness PSR and Life Safety Code PSR, Colonial Nursing Home was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 55
Census: 36
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Aug 3, 2023
Visit Reason
This visit was for the investigation of Complaint IN00414240.
Findings
No deficiencies related to the allegations in Complaint IN00414240 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00414240 - No deficiencies related to the allegations are cited.
Report Facts
Census: 34
Total Capacity: 34
Medicare Residents: 2
Medicaid Residents: 26
Other Payor Residents: 6
Inspection Report
Life Safety
Census: 35
Capacity: 55
Deficiencies: 11
Jul 20, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 07/20/2023.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including emergency power system testing, building construction type, stairway enclosures, emergency lighting, fire alarm and sprinkler system policies, fire door inspections, electrical receptacle testing, and power cord usage. Several deficiencies were related to incomplete or missing documentation and failure to conduct required inspections and tests.
Severity Breakdown
SS=F: 10
SS=E: 1
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing monthly load testing and weekly visual checks of generator. | SS=F |
| Building construction type was not acceptable as required by NFPA 101 - 2012 edition for a two-story existing healthcare building. | SS=F |
| Failed to provide and maintain exit stairs and exit stair enclosures in accordance with NFPA 101 - 2012 edition; issues with fire resistance rating, stair construction, landing spacing, and stair width. | SS=E |
| Failed to ensure 8 of 8 battery backup emergency lights were tested monthly as required. | SS=F |
| Failed to provide correct written policy for fire alarm system out of service procedures. | SS=F |
| Failed to maintain sprinkler system in accordance with NFPA 25; no monthly inspection of wet pipe sprinkler system gauges and valves for past 12 months. | SS=F |
| Failed to provide correct written policies for sprinkler system out of service procedures including fire watch policy. | SS=F |
| Failed to ensure annual inspection and testing of 7 of 7 fire door assemblies; no documentation of annual inspection available. | SS=F |
| Failed to ensure non-hospital grade electrical receptacles at 29 resident sleeping rooms were tested at least annually. | SS=F |
| Failed to maintain complete written record of monthly generator load testing for 2 of 12 months and weekly inspection for 8 of 52 weeks. | SS=F |
| Failed to ensure 3 of 3 power strips were not used as a substitute for fixed wiring to provide power to equipment with high current draw; misuse of extension cords and power strips observed. | SS=D |
Report Facts
Certified beds: 55
Census: 35
Deficiencies cited: 12
Fire door assemblies: 7
Resident sleeping rooms: 29
Generator load testing months missing: 2
Weekly generator inspections missing: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Named as facility representative during survey |
| Regional Director | Interviewed and provided information regarding deficiencies and findings | |
| Maintenance Director | Referenced in relation to deficiencies in generator testing, emergency lighting, sprinkler system inspections, electrical receptacle testing, and power strip usage |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 15
Jun 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00407030, IN00409011, IN00410504, and IN00411495.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, comprehensive care planning, discharge planning and summary, quality of care, pain management, nurse staffing postings, food preparation and sanitation, infection control, environmental safety, and personnel training.
Complaint Details
Complaint IN00407030 had federal/state deficiencies cited at F697 and F921. Complaint IN00409011 had no deficiencies related to the allegations. Complaint IN00410504 had no deficiencies related to the allegations. Complaint IN00411495 had federal/state deficiencies cited at F660, F661, and F921.
Severity Breakdown
SS=A: 1
SS=C: 1
SS=D: 7
SS=E: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to antidepressant medication use for 1 of 13 MDS assessments reviewed. | SS=A |
| Failed to ensure a comprehensive care plan was in place for a resident receiving an antipsychotic medication for 1 of 13 residents whose care plans were reviewed. | SS=D |
| Failed to ensure a resident was invited to their care plan conference for 1 of 13 residents whose plans of care were reviewed. | SS=D |
| Failed to develop and implement an effective discharge planning process related to lack of planning, education, and supplies for a resident's caregivers on ileostomy care before discharge. | SS=D |
| Failed to ensure a discharged resident had a discharge summary completed, including a post-discharge plan of care with the resident and responsible party, for 1 of 2 residents reviewed for discharges. | SS=D |
| Failed to ensure a lymphedema sleeve was applied as ordered and a scabbed area was assessed and monitored for 1 of 1 residents reviewed for edema and non-pressure skin conditions. | SS=D |
| Failed to ensure pain medications were available for a newly admitted resident experiencing pain for 1 of 1 residents reviewed for pain management. | SS=D |
| Failed to have accurate daily nurse staffing postings; daily facility census number was not listed on the forms. | SS=C |
| Failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to labs not completed as ordered for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure food was prepared in form to meet individual needs related to not following a recipe for pureed food. | SS=D |
| Failed to ensure food was served and stored under sanitary conditions related to unlabeled and expired food in the refrigerator, dirty refrigerator shelves, lack of hand hygiene during food preparation, dirty utensil bins and a broken oven door. | SS=E |
| Failed to ensure infection control guidelines were in place and implemented related to improper cleaning of reusable equipment for 3 of 4 medication pass observations. | SS=D |
| Failed to ensure employees received screening or education related to tuberculosis at least annually and received the required annual training for 2 of 5 employees reviewed. | — |
| Failed to provide at least 80 square feet per resident in multiple resident rooms and 100 square feet in single occupancy rooms in 8 of 30 resident rooms. | SS=E |
| Failed to maintain a functional, safe, and homelike environment related to bent or loose baseboard heater covers, marred and gouged doors and walls, a ripped and torn wheelchair armrest, loose thermostat cover and broken floor tiles for 4 of 30 resident rooms and 2 of 2 units. | SS=E |
Report Facts
Census: 33
Total Capacity: 33
Deficiencies cited: 14
Pureed food recipe measurements: No specific measurements used during food preparation
Room measurements: 96.2
Room measurements: 75.2
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 30, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Complaints IN00407030 and IN00411495.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review to the Recertification and State Licensure survey and complaint investigation.
Complaint Details
Investigation of Complaints IN00407030 and IN00411495 was included in the review.
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 9
Feb 21, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00399626, IN00400138, IN00400247, IN00400504, and IN00401479) regarding alleged deficiencies at Colonial Nursing Home.
Findings
The facility was found to have multiple substantiated deficiencies including failure to prevent abuse and neglect, medication misappropriation, inadequate ADL care, failure to follow physician orders for compression stockings, incomplete fall investigations and interventions, poor food quality and temperature control, infection control lapses during medication administration, and maintenance issues affecting the sanitary and homelike environment.
Complaint Details
The investigation was triggered by complaints IN00399626, IN00400138, IN00400247, IN00400504, and IN00401479. All complaints were substantiated with related federal/state deficiencies cited.
Severity Breakdown
SS=D: 6
SS=E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to protect a resident from verbal and mental abuse by staff. | SS=D |
| Failure to ensure residents were free from misappropriation of property during medication administration. | SS=D |
| Failure to implement abuse/neglect policies including employee screening. | SS=D |
| Failure to provide necessary ADL care in a timely manner to dependent residents. | SS=E |
| Failure to ensure physician ordered interventions for compression stockings were followed. | SS=D |
| Failure to thoroughly investigate resident falls and implement appropriate interventions. | SS=D |
| Failure to serve food at safe and appetizing temperatures and ensure palatable meals. | SS=E |
| Failure to maintain infection control practices during medication administration. | SS=D |
| Failure to maintain a sanitary and homelike environment due to stained ceiling tiles, scraped walls, and loose wall protectors. | SS=E |
Report Facts
Survey dates: 2023-02-17 to 2023-02-21
Census: 32
Total Capacity: 32
Deficiency completion dates: Mar 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed the report and involved in investigation oversight. |
| Nurse 1 | Named in medication misappropriation and infection control deficiencies. | |
| CNA 3 | Named in verbal abuse allegations. | |
| CNA 4 | Named in verbal abuse allegations and suspended. | |
| Director of Nursing | DON | Provided interviews and oversight related to medication administration and abuse policies. |
| Business Office Manager | Provided interview regarding employee background checks. | |
| Cook 1 | Interviewed regarding food preparation and temperature issues. | |
| Dietary Manager | Interviewed regarding food preparation and temperature issues. | |
| Maintenance Director | Responsible for facility maintenance and repairs. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to multiple complaint investigations (IN00399626, IN00400138, IN00400247, IN00400504, and IN00401479).
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to the investigation of complaints IN00399626, IN00400138, IN00400247, IN00400504, and IN00401479. The facility was found to be in compliance based on paper review.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 17, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00395293 and IN00396866 completed on December 16, 2022.
Findings
Colonial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00395293 and IN00396866. Compliance was found in the paper review.
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 3
Dec 15, 2022
Visit Reason
This visit was for the investigation of complaints IN00395293 and IN00396866, both substantiated with related federal/state deficiencies cited.
Findings
The facility failed to provide treatments and care in accordance with professional standards, specifically regarding pain assessment and medication administration for multiple residents. Additionally, the facility failed to post accurate nurse staffing information and did not ensure licensed nurse supervision and authorization for PRN pain medications administered by QMA staff.
Complaint Details
Complaint IN00395293 was substantiated with deficiencies cited at F732. Complaint IN00396866 was substantiated with deficiencies cited at F684 and F9999.
Severity Breakdown
SS=E: 1
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assess pain prior to administration and effectiveness after administration of pain medications for 4 of 5 residents reviewed. | SS=E |
| Failure to post and provide accurate nurse staffing information daily. | SS=C |
| Failure to ensure licensed nurse supervision and authorization for PRN pain medications administered by QMA staff for 4 of 5 residents reviewed. | — |
Report Facts
Census: 31
Total Capacity: 31
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Short | Administrator | Signed report and acknowledged findings |
| LPN 3 | Interviewed regarding lack of licensed nurse pain assessments | |
| LPN 7 | Interviewed regarding lack of licensed nurse pain assessments | |
| Director of Nursing | Director of Nursing | Acknowledged missing documentation and assessments on MARs and lack of pain assessments; provided policies and in-service details |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 12, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint Number IN00385384 from 07/19/22.
Findings
Colonial Nursing Home was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Complaint Details
Investigation of Complaint Number IN00385384 conducted on 07/19/22 with paper compliance completed on 10/12/22.
Inspection Report
Re-Inspection
Census: 35
Capacity: 55
Deficiencies: 7
Sep 7, 2022
Visit Reason
A Post Survey Revisit was conducted on the Life Safety Code Recertification and State Licensure Survey to verify correction of previous deficiencies and compliance with Medicare/Medicaid participation requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements including building construction type, stairways and smokeproof enclosures, sprinkler system maintenance, portable fire extinguisher maintenance, corridor door closures, HVAC combustion air intake, and fire drill procedures. The facility had not completed required fire alarm system upgrades and failed to implement systemic plans of correction to prevent recurrence of cited deficiencies.
Severity Breakdown
SS=E: 4
SS=D: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility was not an acceptable type of construction (Type V(000)) for a two-story healthcare building. | — |
| Failed to provide and maintain exit stairs and exit stair enclosures in accordance with NFPA 101. | SS=E |
| Failed to ensure ceiling construction was maintained as indicated in the plan of correction. | SS=E |
| Failed to ensure portable fire extinguishers were properly maintained in accordance with NFPA 10. | SS=E |
| Failed to ensure corridor doors had no impediment to closing and latching; doors were propped open. | SS=E |
| Failed to ensure laundry room fuel fired dryers had intake combustion air from outside. | SS=D |
| Failed to ensure fire drills included verification of transmission of fire alarm signal to monitoring station. | SS=F |
Report Facts
Certified beds: 55
Census: 35
Deficiency citation date: Jun 6, 2022
Plan of correction completion date: Feb 15, 2023
Plan of correction completion date: Oct 7, 2022
Number of residents potentially affected by stairway deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Administrator | Interviewed regarding facility construction type, fire alarm system upgrades, and deficiencies | |
| Maintenance Director | Interviewed and involved in record review, responsible for maintenance and corrective actions related to fire safety deficiencies |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Jul 26, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00386216.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00386216 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 36
Medicare Census: 5
Medicaid Census: 27
Other Payor Census: 4
Inspection Report
Life Safety
Deficiencies: 0
Jun 6, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 06/06/22 and the Post Survey Review conducted on 09/07/22.
Findings
Colonial Nursing Home was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
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