Colonial Manor of Elma

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to protect 1 of 2 resident's rights to be free from misappropriation of their opioid pain medication patches (fentanyl) (an extremely potent, synthetic (lab-made) opioid used for pain) (Resident #42). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 documented a Brief Interview for Mental Status (BIMS) of 9, indicating moderate cognitive impairment. The MDS included diagnoses of low back pain, age related osteoporosis, and limitation of activities due to disability. The MDS reflected she took an opioid medication during the lookback period.Resident #42's Order Summary Report signed by her doctor on 10/24/25 included an order for a fentanyl patch 25 milligrams (mg) with a start date of 10/1/25. Resident #42's Orders in her Electronic Health Record (EHR) included an order for a fentanyl patch 25 mg with a start date of 10/1/25 and an end date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #35). The facility identified a census of 36.Findings include:Resident #35's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00, indicating a severe cognitive loss. The MDS listed diagnoses of non-Alzheimer's dementia and anxiety. The MDS reflected Resident #35 used an anti-anxiety medication during the lookback period. An Order Summary Report signed by the Provider on 12/11/25 documented an order dated 11/7/25 for lorazepam (anti-anxiety, psychotropic medication) oral tablet 0.5 milligrams (MG), give 0.5 tablet by mouth every 2 hours as needed (PRN) for anxiety/restlessness.The Care Plan Focus dated 2/11/25 indicated Resident #35 utilized psychotropic medication in the category of anti-anxiety medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code 2 of 2 Minimum Data Set (MDS) assessments for residents with a Pre-admission Screening and Resident Review (PASRR) Level II outcome (a formal determination that confirms if an individual with suspected serious mental illness or intellectual disability requires Medicaid-certified nursing facility care and defines their need for specialized services) (Resident #4 and #32). The facility reported a census of 36 residents. Findings include:1. Resident #4's MDS assessment dated [DATE] identified she didn't have a state level II PASRR serious mental illness and/or intellectual disability or related condition. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, bipolar, and schizophrenia. Resident #4's PASRR notice of nursing facility approval dated 12/2/15 reflected she met the criteria for mental illness as defined by PASRR. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to provided 1 of 2 residents with specialized services as the resident's Pre-admission Screening and Resident Review (PASRR) directs (Resident #4). The facility reported a census of 36 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, bipolar, and schizophrenia. Resident #4's PASRR dated 12/2/15 directed she required specialized services of a behavior management plan for addressing behaviors of anxiety/worry, verbal aggression, abrasiveness/irritable behaviors and inappropriate communication of anger. Review of Resident #4 Care Plan on 2/17/16 lacked a behavior management plan. In an interview on 2/19/26 at 2:06 PM the Director of Nursing (DON) reported she didn't have a behavior management plan for Resident #4.In an e-mail correspondence with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, resident, and staff interview, the facility failed to ensure appropriate infection control prevention and practices to prevent cross contamination when providing incontinent cares. The observation revealed the staff failed to remove soiled gloves, perform hand hygiene, and not touch a clean brief with soiled gloves for 1 of 2 residents observed (Resident #7). The facility identified a census of 36 residents.Findings include:Resident #7's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. Resident #7 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) with lower body dressing and toileting hygiene. The MDS documented she is not on a toileting program and is frequently incontinent for bowel and bladder. The MDS included diagnoses of renal (kidney) failure, diabetes mellitus,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to obtain daily weights and notify the Doctor of a 3-pound (lb.) weight gain is identified in a day as the Doctor ordered for 1 of 1 resident reviewed for nutrition (Resident #6). The facility reported a census of 36 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. The MDS documented diagnoses of aphasia (difficulty swallowing), metabolic encephalopathy (brain dysfunction caused by underlying systemic diseases, toxic exposure, or electrolyte imbalances), and acute respiratory failure. Review of Resident #6 Order Summary Report signed by his doctor on 11/25/25 documented an order to obtain daily weights and notify the doctor of weight greater than 3 lb. in a day and 5 lb. in a week starting 9/12/25Review of Resident #6 Weights in his Electronic Health Record (EHR) from 11/20/25 to 2/18/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review and staff interview, the facility failed to ensure infection control prevention and practices to prevent touching of medication with bare hands or dirty gloves during medication administration for 3 of 5 residents observed (Residents #27, #1, and #11). The facility identified a census of 36 residents.Findings include:Observation completed during the Medication Administration Task revealed the following:A. On 2/19/26 at 7:07 AM Staff B, Certified Medication Aide (CMA), voiced she planned to give Resident #27 his medications. Staff B without performing hand hygiene applied gloves, obtained her keys, opened the double lock narcotic drawer, touched the computer mouse with her right gloved hand to check the physician order. Staff B touched multiple resident medication cards in the narcotic drawer, retrieved Resident #27's Methadone (narcotic medication) card, punched the pill into her right gloved hand, and placed it into the medication cup. Staff B administered the medication to Resident #27.B. On 2/19/26 at 7:14 AM Staff B, opened the drawers on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed to implement a Care Plan chair alarm intervention for 1 of 3 residents reviewed for falls (Resident #3). The facility reported a census of 31 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 2 out of 15, which indicated severe cognitive impairment. The MDS documented the need for substantial/maximal assistance (staff did more than half the effort) for transfers and walking up to 50 feet. The MDS also documented diagnoses of non-Alzheimer's dementia, anxiety, respiratory failure, and adult failure to thrive.The Care Plan created 2/18/25 revealed, Resident is at risk for falls. The Intervention initiated 2/24/25 and created on 3/6/25 revealed, Chair alarm placed to alert staff when I am self transferring. Review of the Witness Statement for Staff A License Practical Nurse (LPN) dated 4/30/25 at 11:45 AM documented on 4/25/25 she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, resident and staff interviews, the facility failed to treat a resident with dignity and respect for 1 of 3 residents sampled (Resident #4). The facility identified a census of 30 residents. Findings include: Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. During an interview on 2/11/25 at 4:01 PM Resident #4 reported Staff B, Certified Nursing Assistant (CNA) came into her room during the night and started mouthing off yelling Staff A, Licensed Practical Nurse (LPN), that fucking fat ass he doesn't do anything, repeatedly. He sits on his butt all night and then goes outside to smoke every two hours. Then Staff B left the room. Resident #4 voiced Staff B is rude at times and she doesn't feel that Staff B should be talking to her about other employees or residents. She is always complaining how she can't take care of Resident #27 because she doesn't want…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, clinical record review, and staff interview, the facility failed to utilize appropriate EBP per the CDC during the provision of catheter care to minimize the risk of cross contamination that may lead to the spread of multi-drug resistant organisms for 3 of 3 residents sampled (Residents #5, #4, and #10). The facility reported a census of 30 residents. Findings include: 1. Resident #5 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating moderate cognitive impairment. It documented Resident #5 had diagnoses of renal insufficiency, neurogenic bladder, and Cerebral Palsy. The MDS further documented Resident #5 utilized an indwelling catheter for a diagnosis of neurogenic bladder. A 8/26/23 review of Resident #5 Electronic Healthcare Record (EHR) listed a Physician Order for a 16 French (size) Foley catheter to be continued. The Care Plan with an undated focus date directed Resident #5 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 35 residents. Findings include: During an interview on 4/29/24 at 9;50 AM, the Dietary Manager reported the facility is working on getting her enrolled in the dietary manager classes. During an interview on 4/30/24 at 10:42 AM, the Consultant Dietician reported the Dietary Manager is not certified but currently in the course. She reported when she is in the building it varies when she comes but reviews the residents at least once a week. Review of the Dietary Manager's employee file lacked documentation of a certificate of completion of the Dietary Manager courses.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to follow physician orders for 1 of 2 residents reviewed (Resident #17). The facility reported a census of 35 residents. Finding include: Resident #17 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS include diagnoses of benign prostatic hyperplasia, anxiety, and hypertension Review of Resident #17's Electronic Health Record (EHR) revealed a Physician Order for referral to Urology on 1/22/24. Review of the Progress Notes lacked documentation of an appointment being made or call out to make the appointment. During an interview on 5/01/24 at 11:12 AM, the Director of Nursing (DON) reported there was no documentation of any call to Urology nor an appointment scheduled to see Urology for Resident #17. She reported she talked with the nurse who noted the order and was not sure why it was not done. The DON reported she expected staff to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure assessments were done for 1 of 2 residents reviewed to determine if she remained at baseline or had a decline (Resident #15). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], documented Resident #15 had impairment on both sides of her upper and lower extremities. Review of Resident #15's Care Plan revealed this resident was not on a restorative care program. On 4/29/24 at 11:30 a.m., Resident #15 was observed laying in her bed. On 4/29/24 at 1:02 p.m., Resident #15 was up and dressed sitting in the room recliner, yelling out to lay down in bed for 8 minutes. No call light on, just periodically yelling for help. Staff went in at this time and placed a gait belt on the resident and reported they would assist her to lay down. On 5/1/24 at 1:34 p.m., Resident #15 was sitting in her recliner, eyes were closed. She didn't respond to the knock at the door. Door was open, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.