Inspection Reports for Colonial Woods
1710 CREEK ROAD,, GLENMOORE, PA, 19343
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
35.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
662% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year
Deficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
84% occupied
Based on a February 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 26
Capacity: 31
Deficiencies: 6
Date: Feb 10, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and address complaints.
Complaint Details
The visit included a complaint investigation related to staff behavior intimidating residents during meals and other compliance issues.
Findings
The inspection identified multiple deficiencies including resident mistreatment by staff, failure to conduct timely criminal background checks, unsanitary bathroom conditions, incomplete posting of weekly menus, inaccurate medication documentation, and incomplete annual medical evaluations. Plans of correction were accepted and fully implemented by April 14, 2025.
Deficiencies (6)
Staff Person A exhibited hostile behavior towards residents, including yelling and intimidating residents during meals, violating their dignity and respect.
Staff Person B did not have a criminal background check requested on or before their start date, a repeat violation.
Shared bathroom across from Apartment 20 had a strong odor of urine, indicating unsanitary conditions, a repeat violation.
Weekly menu for the upcoming week was not displayed in a conspicuous and public place in the home.
Blood glucose readings for Resident 3 were inaccurately documented on multiple occasions.
Resident 2’s most recent annual medical evaluation was not completed timely.
Report Facts
License Capacity: 31
Residents Served: 26
Staffing: 26
Waking Staff: 20
Residents Receiving SSI: 6
Residents Age 60 or Older: 21
Residents Diagnosed with Mental Illness: 17
Repeat Violation Date: 2024
Inspection Report
Monitoring
Census: 22
Capacity: 31
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
The inspection was a monitoring visit conducted on 03/28/2024 to assess compliance at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 20
Total Daily Staff: 42
Waking Staff: 32
Residents Served: 22
License Capacity: 31
Residents Receiving Supplemental Security Income: 4
Residents 60 Years of Age or Older: 17
Residents Diagnosed with Mental Illness: 15
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Current Hospice Residents: 0
Inspection Report
Follow-Up
Census: 20
Capacity: 31
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
The inspection visit on 02/21/2024 was a complaint-related partial inspection conducted to review the submitted plan of correction for the facility.
Complaint Details
The inspection was complaint-related, with the reason stated as 'Complaint'. The plan of correction was accepted and fully implemented as of 03/18/2024.
Findings
The submitted plan of correction was determined to be fully implemented, addressing deficiencies related to incomplete medical evaluations for residents. Continued compliance must be maintained.
Deficiencies (1)
Resident medical evaluations did not include medical information pertinent to diagnosis and treatment in case of an emergency, special health or dietary needs, medication regimen, contraindicated medications, medication side effects, and ability to self-administer medications.
Report Facts
License Capacity: 31
Residents Served: 20
Total Daily Staff: 20
Waking Staff: 15
Residents 60 Years or Older: 15
Residents Diagnosed with Mental Illness: 14
Residents Receiving Supplemental Security Income: 4
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in plan of correction for correcting medical evaluation deficiencies |
| Administrator B | Administrator | Named in plan of correction for double checking corrections to medical evaluations |
Inspection Report
Renewal
Census: 20
Capacity: 31
Deficiencies: 25
Date: Jan 10, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 01/10/2024.
Complaint Details
The inspection included complaint investigation as one of the reasons for the visit. Specific complaint details are not explicitly stated beyond the violations found.
Findings
The inspection identified multiple deficiencies including failure to report an incident, incomplete criminal background checks, missing staff on contact lists, inadequate staff training, sanitary and safety hazards, medication storage issues, and fire safety violations. Plans of correction were accepted and implemented by 03/28/2024.
Deficiencies (25)
Failure to submit an incident report for a resident fall resulting in injury.
Administrator's staff record lacked an updated criminal background check after returning from employment absence.
Administrator's staff list did not include a staff person.
Only one staff member held current CPR certification, leaving no CPR certified staff during daytime hours.
Administrator had not completed required 100-hour standardized administrator training course prior to initial employment.
New staff member did not receive timely orientation on fire safety and emergency preparedness topics.
New staff member had not completed required training on reporting reportable incidents and conditions within 40 scheduled hours.
No staff training plan developed for 2024.
Sanitary conditions not maintained: dried substance under sink, soiled toilet splash guards, black mold in shower, strong urine odor in room.
Uncovered trash can found in bathroom.
Loose floor boards, torn/frayed carpeting, and peeling floor boards creating hazards.
Inoperable dryer and oven.
Deck boards popping up causing tripping hazard.
Wet, slippery leaves obstructing emergency exit.
Broken or missing window blinds in bedroom.
Use of common towels in shared bathroom.
Unlabeled and undated food items in refrigerators and freezer.
Personal items blocking egress from exit window in resident room.
Portable space heater found in sun room.
Fire drill schedule improperly kept in medication room accessible to staff.
Evacuation times exceeded 4 minutes 30 seconds during fire drills, corrected to allow 7 minutes.
Overnight fire drills not conducted within required 6-month interval.
Residents reported not participating in fire drills since moving in or since weather got cold.
Prescription medication for a cat was unlocked and accessible in common area refrigerator.
Tape found on back of blister pack for resident's prescription medication.
Report Facts
License Capacity: 31
Residents Served: 20
Staff Total Daily: 20
Waking Staff: 15
Evacuation Time: 270
Fire Drill Interval: 6
Inspection Report
Renewal
Census: 23
Capacity: 31
Deficiencies: 13
Date: Sep 8, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at the facility.
Findings
The inspection identified multiple deficiencies including issues with training plan content, sanitary conditions, lighting, soap dispensers, refrigerator temperatures, emergency procedure submissions, unobstructed egress, fire drills, medication storage and administration, and following prescriber's orders. All deficiencies had plans of correction submitted and were implemented by early 2023.
Deficiencies (13)
The home's staff training plan does not include the dates, times and locations of the scheduled training for each staff person for the upcoming year.
Black/green slimy mold-like substance present on caulking in shower stall of main level big bathroom; improper use of resident #1's glucometer.
Resident #3 does not have access to a source of light that can be turned on/off at bedside.
Two unlabeled, used bars of soap found in cabinet above sinks in main level big bathroom.
No thermometer in the mini refrigerator on the upper level living room.
Written emergency procedures have not been submitted to the local emergency management agency since 6/11/2021.
A small table with personal belongings blocked egress from the emergency exit window in room 10.
An unannounced fire drill was not held during the month of February 2022.
The last fire safety inspection by a fire safety expert was conducted on 7/5/2021.
No fire drill conducted during sleeping hours from 12/1/2021 to 8/31/2022.
Resident #1's glucose and insulin coverage documentation was incorrect due to staff not verifying resident-reported glucose readings.
Resident #1 prescribed medication was not available in the home as ordered.
Staff persons A and B administered insulin to resident #1 without successfully completing a Department-approved diabetes patient education program within the last 12 months.
Report Facts
License Capacity: 31
Residents Served: 23
Staffing Hours: 23
Waking Staff: 17
Residents with Supplemental Security Income: 5
Residents 60 Years or Older: 18
Residents Diagnosed with Mental Illness: 17
Residents Diagnosed with Intellectual Disability: 1
Hospice Residents: 1
Inspection Report
Follow-Up
Census: 23
Capacity: 31
Deficiencies: 1
Date: Mar 9, 2022
Visit Reason
The inspection was a complaint-related partial review conducted off-site on 03/09/2022 to follow up on a previously submitted plan of correction.
Complaint Details
The visit was complaint-related and conducted as a partial inspection with an exit conference on 03/09/2022. The plan of correction submission was followed up on 03/27/2022.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. A deficiency was noted regarding the lack of a nationally recognized food manager certification among staff preparing food for residents.
Deficiencies (1)
No staff person employed by the home had obtained a nationally recognized food manager certification as required by the PA Department of Agriculture Food Employee Certification Act.
Report Facts
Residents served: 23
License capacity: 31
Staffing hours: 23
Waking staff: 17
Completion date for food manager certification: Apr 15, 2022
Inspection Report
Complaint Investigation
Census: 22
Capacity: 31
Deficiencies: 7
Date: Feb 3, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by a complaint received by the Department of Human Services. The complaint involved resident abuse and other regulatory concerns. The complaint was substantiated as deficiencies were found and documented.
Findings
The inspection found multiple deficiencies including delayed reporting of resident abuse, insufficient direct care staffing hours, inadequate documentation of medication administration times, lack of support plans for resident behavioral issues, and incomplete resident records. The facility submitted a plan of correction which was accepted and implemented.
Deficiencies (7)
Delayed submission of ACT 13 form for a resident abuse incident observed on 1/17/22.
Failure to report a resident abuse incident to the department within 24 hours.
Insufficient direct care staffing hours provided on 1/22/22; 20 hours provided instead of required 22 hours.
Less than 75% of personal care service hours provided during waking hours on 1/22/22; only 13.5 hours of required 22 hours provided.
Medication administration record not initialed at the time medication was administered on 1/24/22.
No support plan in place to address irritability, agitation, and aggressive behaviors for resident #1.
Resident #1's record did not include the incident report dated 1/17/22.
Report Facts
Residents served: 22
License capacity: 31
Direct care hours required: 22
Direct care hours provided: 20
Waking hours required: 16.5
Waking hours provided: 13.5
Residents receiving Supplemental Security Income: 5
Residents aged 60 or older: 20
Residents diagnosed with mental illness: 19
Inspection Report
Follow-Up
Census: 22
Capacity: 31
Deficiencies: 14
Date: Jan 27, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by complaint and monitoring reasons to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related and monitoring in nature. Specific complaint details are not provided, but the inspection focused on verifying correction of prior deficiencies.
Findings
The facility was found to have implemented the submitted plan of correction fully. Several deficiencies were identified related to resident care, staff training, reporting of incidents, and documentation, all of which had corrective plans accepted and were in the process of being implemented.
Deficiencies (14)
Resident #1 did not receive required assistance with securing and using transportation as indicated in the assessment and support plan.
Menus for the weeks of 01/24/22 and 01/31/22 were not posted in a conspicuous and public place in the home.
Staff person C transported residents without completing the initial new hire direct care staff training.
Resident #2's additional annual assessment was not completed timely.
Resident #1's assessment and support plan did not document aggressive behavior or how this need would be met.
Allegation of resident abuse was not reported timely to the local Area Agency on Aging and Department.
Staff person C did not complete required 40-hour orientation training including resident rights, emergency medical plan, abuse reporting, and reportable incidents.
Staff person A did not receive fire safety orientation training on the first day of work.
Staff person A did not complete required 40-hour orientation training including resident rights, emergency medical plan, abuse reporting, and reportable incidents.
Staff person A did not complete and pass the Department-approved direct care training and competency test until after hire date.
Resident 3's glucometer was not calibrated to the correct date and time.
Resident 1's initial assessment was not completed within 15 days of admission.
Resident 1's initial support plan was not completed within 30 days of admission.
Resident 2's records did not include the prescreen form.
Report Facts
License Capacity: 31
Residents Served: 22
Total Daily Staff: 22
Waking Staff: 17
Residents Served: 23
License Capacity: 31
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Complaint Investigation
Census: 18
Capacity: 31
Deficiencies: 8
Date: Sep 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 09/27/2021.
Complaint Details
The inspection was complaint-driven, triggered by concerns related to resident abuse and medication administration errors. The complaint was substantiated with findings of unreported suspected abuse and medication documentation errors.
Findings
The inspection identified multiple deficiencies including failure to report suspected resident abuse, improper documentation of glucometer readings and medication administration, inadequate dietary alternatives and special diet adherence, and sanitary condition violations related to shared glucometer use. Plans of correction were accepted and implemented with education and monitoring.
Deficiencies (8)
Failure to immediately report suspected abuse of a resident with bruises after hospitalization.
Failure to report the incident to the Department within 24 hours as required.
Use of one resident's glucometer device to read another resident's glucose readings.
Resident's annual medical evaluation was not current at the time of inspection.
At breakfast, no alternative food was available on the posted menu; menu contained high fat and sodium meals and lacked vegetables or fruit on 9/20.
Resident prescribed a heart-healthy, low cholesterol diet was served inappropriate foods such as fried eggs and french toast with syrup.
Discrepancies between glucometer readings and Medication Administration Record (MAR) entries for resident's blood glucose levels.
Failure to follow prescriber's orders for insulin dosage based on glucometer readings, resulting in incorrect medication administration.
Report Facts
License Capacity: 31
Residents Served: 18
Staffing: 18
Waking Staff: 14
Residents Diagnosed with Mental Illness: 18
Residents Age 60 or Older: 12
Residents Receiving Supplemental Security Income: 4
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter confirming plan of correction implementation. |
Notice
Deficiencies: 0
Date: Sep 3, 2021
Visit Reason
The document serves to grant a waiver for the training requirements under 55 Pa.Code § 2600.64(a)(2)-(3) for a personal care home administrator at Colonial Woods Personal Care Home, allowing additional time to complete the required training and competency test.
Findings
The waiver is granted with conditions including completion of a 100-hour standardized training course and a competency-based test within 2021, with documentation to be maintained by the facility and reviewed during the annual inspection.
Report Facts
Training hours: 100
Inspection Report
Follow-Up
Census: 20
Capacity: 31
Deficiencies: 3
Date: Aug 31, 2021
Visit Reason
The inspection was an unannounced partial licensing inspection conducted on 08/31/2021 with an interim reason and a follow-up type of POC (Plan of Correction) submission.
Findings
The inspection identified deficiencies related to medication administration and glucose monitoring documentation for Resident #1, including missing insulin administration records and inconsistent glucose meter readings. The facility submitted an acceptable plan of correction.
Deficiencies (3)
Failure to accurately document insulin administration units on the medication administration record for Resident #1 despite recorded glucose readings.
Inconsistent glucose meter readings recorded on the log compared to actual meter readings for Resident #1.
Failure to follow prescriber's orders for glucose checks before meals and at bedtime, with an unclear source for a recorded glucose reading.
Report Facts
License Capacity: 31
Residents Served: 20
Total Daily Staff: 20
Waking Staff: 15
Residents Receiving Supplemental Security Income: 4
Residents 60 Years or Older: 15
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Notice
Deficiencies: 0
Date: Aug 27, 2021
Visit Reason
The document serves to grant a waiver request allowing additional time for an employee at Colonial Woods Personal Care Home to complete the required 100-hour administrator training course and competency-based test.
Findings
The waiver is granted under specific conditions including completion of training between September 28 and December 16, 2021, and documentation requirements. The Department will review compliance with this waiver during the annual inspection.
Report Facts
Training course hours: 100
Training course dates: Scheduled from September 28, 2021 through December 16, 2021
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 5
Date: Aug 2, 2021
Visit Reason
The inspection was a monitoring visit conducted on August 2, 2021, to review compliance with previously submitted plans of correction.
Findings
The inspection found multiple medication administration deficiencies, including failure to follow prescriber's insulin orders and staff administering medication without proper certification. Plans of correction were accepted and fully implemented by June 15, 2022.
Deficiencies (5)
Staff person A administered incorrect insulin doses to Resident #1, not following the prescribed sliding scale orders.
Staff person B administered medications without completing the required Department-approved medication administration course.
Staff person B administered insulin without completing required diabetic education.
Medication Administration Record (MAR) reviews and medication observations for Staff persons C and D were not completed 6 months apart as required.
Inaccurate documentation and storage procedures for medication and glucometer use were identified, including missing insulin administration records and unclear glucose readings.
Report Facts
License Capacity: 31
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Residents Diagnosed with Mental Illness: 18
Residents 60 Years or Older: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for administering incorrect insulin doses. | |
| Staff person B | Named in deficiency for administering medication and insulin without current certification and diabetic education. | |
| Staff person C | Named in deficiency for incomplete Medication Administration Record reviews. | |
| Staff person D | Named in deficiency for incomplete Medication Administration Record reviews. |
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 4
Date: Aug 2, 2021
Visit Reason
The inspection was a monitoring visit conducted on 08/02/2021 to assess compliance with Department statutes and regulations at Colonial Woods facility.
Findings
The inspection found multiple deficiencies related to medication administration, including staff not following prescriber's insulin orders, staff administering medications without completing required training, and failure to complete medication administration record reviews at required intervals. Plans of correction were accepted with measures to improve staff training and monitoring.
Deficiencies (4)
Staff person A administered incorrect insulin doses to Resident #1, not following the prescribed sliding scale orders.
Staff Person B administered medications without successfully completing the Department-approved medication administration course.
Staff Person C and Staff Person D did not have Medication Administration Record (MAR) reviews and medication observations completed 6 months apart as required.
Staff Person B administered insulin injections without completing the required diabetic education within the past 12 months.
Report Facts
License Capacity: 31
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 12
Residents Diagnosed with Mental Illness: 18
Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for not following prescribed insulin orders and receiving additional training | |
| Staff person B | Named in deficiency for administering medications without required training and insulin without diabetic education | |
| Staff person C | Named in deficiency for not completing MAR reviews and medication observations 6 months apart | |
| Staff person D | Named in deficiency for not completing MAR reviews and medication observations 6 months apart |
Inspection Report
Monitoring
Census: 22
Capacity: 31
Deficiencies: 7
Date: May 10, 2021
Visit Reason
The inspection was a monitoring visit conducted on 05/10/2021 as a partial, unannounced inspection to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked resident records, staff not wearing face coverings, missing ceiling tiles due to a leak, improper medication administration by unqualified staff, medication pre-pouring, and inaccurate medication records. Plans of correction were accepted or directed with specified completion dates.
Deficiencies (7)
Resident records and files were unlocked, unattended, and accessible in the main office.
Staff persons A and B were not wearing face coverings while working in the home.
Multiple ceiling tiles, three possibly four, were missing from the ceiling above the lower level entrance due to a leak from the newly installed kitchen cabinets and sink.
Staff person A administered medications without proper qualifications or training as required by regulation.
Evening and night time medications were prepoured by staff person B for staff person A to administer.
Medication administrations by staff person A were not properly logged or were logged under staff person B's initials.
Staff person A administered insulin injections without completing required Department-approved medication administration and diabetes education training.
Report Facts
License Capacity: 31
Residents Served: 22
Total Daily Staff: 22
Waking Staff: 17
Number of Residents 60 Years or Older: 18
Number of Residents Diagnosed with Mental Illness: 18
Number of Residents Receiving Supplemental Security Income: 4
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 10
Date: Apr 23, 2021
Visit Reason
The inspection was a monitoring visit conducted over multiple days from 04/23/2021 to 04/29/2021 to review compliance with licensing regulations and verify the implementation of a submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the current license conspicuously, incomplete criminal background checks, unqualified direct care staff left alone, delayed staff orientation, unsafe floor surfaces, incomplete medical evaluations, non-fire resistant furniture in the smoking area, unsafe medication storage and documentation errors, and inconsistent mobility assessments. Plans of correction were accepted or directed with completion dates mostly in May and June 2021.
Deficiencies (10)
The home's current license was not posted in a conspicuous and public place in the home.
Staff person A did not have a criminal background check completed until 01/13/21.
Staff person B does not have a high school diploma, GED, or active registry status and was left alone as a direct care person from 6:00 AM to 6:30 AM during the work week.
Staff persons A and C did not receive orientation in general fire safety and emergency preparedness on their first day of work.
Several tiles of the kitchen floor were pulled up due to water damage creating a tripping hazard; the access panel to the sewer line was depressed leaving a gap and tripping hazard.
The medical evaluation for resident #1 was not completed within 60 days prior to admission or within 30 days after admission.
The home's designated smoking area had furniture that was not listed as fire resistant.
Staff person B was left alone in the home between 6:00 AM to 6:30 AM and is not trained to provide medications or meet minimum qualifications for direct care.
An error in the count of resident #2's Clonazepam medication was discovered; a second pill pack was not documented.
Resident #3's mobility assessment was inconsistent between the DME and the home's assessment.
Report Facts
License Capacity: 31
Residents Served: 23
Staffing Hours: 23
Waking Staff: 17
Supplemental Security Income: 4
Residents 60 Years or Older: 18
Residents Diagnosed with Mental Illness: 18
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 9
Date: Apr 20, 2021
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review the facility's compliance and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction from a prior inspection. Several deficiencies were identified related to well-balanced meals, dietary needs, medication administration, storage procedures, medication record keeping, and following prescriber's orders, all of which had directed plans of correction with specified completion dates.
Deficiencies (9)
The home did not offer at least three nutritionally well-balanced meals daily with appropriate alternatives.
A resident was served food inconsistent with their prescribed special dietary needs.
Multiple days of blood pressure readings were not taken or recorded as required on the medication administration record (MAR).
Glucometer readings for residents were not consistently logged in the medication administration record.
Controlled medication counts and logs were not properly maintained, and discrepancies were not reported immediately.
Medication errors were not reported in accordance with regulations, and staff lacked proper training on medication administration procedures.
Medication records lacked proper documentation of doses, special precautions, and medication refusals.
Prescriber's orders were not consistently followed, including failure to obtain required accu-check readings and administer insulin as ordered.
Resident records lacked recent photographs taken within the past two years.
Report Facts
License Capacity: 31
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 10
Date: Apr 17, 2021
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to review compliance with regulations and verify the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple violations including staff not wearing face coverings, a staff member sleeping on duty, insufficient staffing levels, missing items in the first aid kit, improper refrigerator/freezer temperatures, inadequate meal offerings, medication administration errors, and medication storage and documentation issues. Plans of correction were submitted and implemented for all deficiencies.
Deficiencies (10)
Staff person A was not wearing a face covering; staff person B entered the home without a face covering.
Staff person A was observed sleeping on the couch while on duty with 23 residents present.
Two staff working is not sufficient to meet the needs of residents; one staff on overnight shift is not sufficient for fire safety.
First aid kit was missing tweezers.
Freezer temperature was 2 degrees Fahrenheit, above the required 0°F.
Breakfast served was donuts and milk, not meeting dietary guidelines.
Home did not identify the correct resident for medication administration for resident #3.
Medication cart audit could not be completed due to dead batteries; no access to medications during overnight shift; residents' glucometer readings and MAR documentation issues.
Medication procedures failed; narcotic counts and documentation were inaccurate; resident #3's medication was administered to resident #4.
The home did not follow prescriber's orders; residents' MAR documentation and medication administration were inaccurate.
Report Facts
License Capacity: 31
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Freezer Temperature: 2
Medication Pills Remaining: 4
Medication Pills Remaining: 21
Inspection Report
Complaint Investigation
Census: 23
Capacity: 31
Deficiencies: 10
Date: Apr 15, 2021
Visit Reason
The inspection was an unannounced partial incident investigation conducted on April 15, 2021, triggered by an incident involving resident abuse and medication administration concerns.
Complaint Details
The complaint involved allegations of resident abuse and neglect, specifically a verbal and physical altercation between staff and Resident 1, failure to report the abuse timely, and medication administration errors. The investigation substantiated these issues with detailed findings.
Findings
The inspection found multiple violations including resident abuse involving verbal and physical altercation, failure to report abuse timely, medication administration errors including failure to observe medication ingestion and improper documentation, lack of staff presence during resident care, and inadequate positive interventions for resident behavior.
Deficiencies (10)
Failure to immediately report suspected abuse of a resident as required by law.
Resident abuse involving verbal and physical altercation between staff and resident.
Staff left the home unattended with residents present, violating designee presence requirements.
Medication administration errors including failure to observe resident swallow medication and improper disposal of refused medication.
Medication procedures not properly followed, including failure to log controlled substance administration.
Medication administration documentation errors, including missed administration times.
Failure to follow prescriber's orders for medication administration.
Lack of positive interventions to modify or eliminate resident behavior that endangers self or others.
Support plan for resident not updated after hospital evaluation and behavioral incident.
Resident record entries were illegible, scratched out, or overwritten in several spots.
Report Facts
License Capacity: 31
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Monitoring
Census: 23
Capacity: 31
Deficiencies: 5
Date: Feb 26, 2021
Visit Reason
The inspection was an unannounced monitoring visit conducted on 02/26/2021 to assess compliance with Department statutes and regulations.
Findings
The inspection identified several deficiencies including lack of CPR/First Aid certified staff during a night shift, missing cover plates on kitchen electrical outlets during a remodel, a tattered mattress cover for a resident, uncalibrated glucometers for residents, and delayed medication administration documentation.
Deficiencies (5)
No staff member trained in first aid and certified in obstructed airway techniques and CPR was present from 10:00pm to 6:00am on 2/20/21.
Missing cover plate on the light switch and receptacle on the kitchen wall near the patio door on 2/26/21.
Mattress cover on the bed for resident #1 was tattered and dingy on 2/26/21.
Glucometers for residents #2 and #3 were not calibrated to the correct date and time on 2/26/21.
Medication administration for resident #4 was not recorded immediately after administration on 2/26/21.
Report Facts
Residents present: 23
Licensed capacity: 31
Total daily staff: 27
Waking staff: 20
Inspection Report
Complaint Investigation
Census: 23
Capacity: 31
Deficiencies: 5
Date: Feb 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted on 02/12/2021 to review compliance with regulations at the Colonial Woods facility.
Complaint Details
The inspection was triggered by a complaint and was an unannounced partial inspection conducted on 02/12/2021.
Findings
The inspection found multiple deficiencies including the administrator lacking required qualifications and training, absence of staff trained in first aid and CPR during certain hours, and delayed orientation and training of staff hired under the previous administrator. The submitted plan of correction was determined to be fully implemented.
Deficiencies (5)
Administrator does not have any of the required qualifications including nursing or administrator licenses or associate degree.
No staff member trained in first aid and certified in obstructed airway techniques and CPR was present from 2:30pm to 10:00pm on 2/6/21 and 1/31/21.
Administrator has not completed the 100-hour standardized Department-approved administrator training course.
Staff person hired under previous administrator did not receive required fire safety orientation until 8/26/20.
Staff person hired under previous administrator did not complete required rights and abuse training within 40 scheduled working hours until 8/26/20.
Report Facts
License Capacity: 31
Residents Served: 23
Staffing Hours: 27
Waking Staff: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Administrator | Named in multiple findings including lack of qualifications, incomplete training, and delayed orientation. |
Notice
Capacity: 31
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Colonial Woods' following receipt of the renewal application dated October 30, 2020.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
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