Inspection Reports for
Colonial Oaks Skilled Nursing and Rehabilitation

The complaint investigation revealed substantiated issues including failure to provide safe medication administration, failure to provide quarterly personal funds statements, failure to provide timely and adequate pain management resulting in immediate jeopardy, failure to develop appropriate care plans for physical restraints, failure to maintain sanitary food service conditions, failure to post required staffing information, failure to accurately document medication administration, and failure to have required members present at quality assurance meetings.

The facility failed to ensure safe medication administration practices, including self-administration assessments and consent, failed to provide quarterly personal funds statements to residents, failed to manage pain medication timely resulting in immediate jeopardy, failed to develop comprehensive care plans for physical restraints, failed to change feeding tube bags every 24 hours, failed to post daily census and staffing information, failed to accurately document pain medication administration, failed to maintain sanitary food storage and preparation conditions, failed to effectively administer resources for pain management, and failed to have required members present at quarterly quality assurance meetings.

The complaint investigation found that Resident #1 sustained a fall on 11/18/2024 which was not reported or documented by the licensed practical nurse (S3LPN). The facility's investigation confirmed the fall occurred and that the nurse failed to complete the required incident report and post-fall assessment. The nurse was terminated for not following facility policy.

The facility failed to ensure a resident fall was reported and documented as required by policy for one of three sampled residents. Specifically, a fall on 11/18/2024 involving Resident #1 was not reported or documented by the responsible licensed practical nurse, who was subsequently terminated.

The complaint involved Resident #2's missing credit card and unauthorized charges on the credit card starting September 2021, totaling $10,000. The facility did not report the suspected misappropriation to the state agency. Resident #2's daughter reported the issue to the facility administrator and filed a police report. Interviews with facility staff confirmed the failure to report the incident to the state agency.

The facility failed to implement policies and procedures to ensure timely reporting of a reasonable suspicion of a crime involving misappropriation of Resident #2's property and financial accounts to the state agency within 24 hours. Resident #2's daughter reported missing credit card charges totaling $10,000, which were not reported to the state agency by the facility despite knowledge of the issue.

The facility failed to complete quarterly resident assessments within the required timeframe for 5 of 8 residents reviewed, failed to develop an accurate and individualized care plan for one resident regarding oral care needs, and submitted inaccurate direct care staffing data to CMS for two dates in December 2023.

The facility failed to respond promptly to resident council concerns, did not honor dietary preferences for at least one resident, and failed to ensure proper sanitation and food handling practices by staff assisting residents with meals.