Colonial Manor II

Based on observation, record review, and interview, the facility failed to assess and monitor a resident before and after dialysis treatments for 1 (#4) of 1 sampled resident reviewed for dialysis.The administrator identified one resident required dialysis services. Findings: On 01/06/26 at 3:20 p.m., Resident #4 pulled up their sleeve and showed the dialysis shunt site on their left forearm to this surveyor. An undated policy titled Dialysis, showed nursing staff would monitor residents before and after dialysis, and dialysis access sites would be protected and observed for signs of infection or complications. The policy showed all dialysis-related care, observations, and communications would be documented in the resident's medical record. A care plan, dated 12/15/25, showed a goal to manage Resident #4's end-stage renal disease while attending dialysis on Tuesday, Thursday, and Saturday. The care plan showed to ensure the resident was safely transported to and from dialysis and the resident was encouraged to report any symptoms related to dialysis. Resident #4's admission…

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, record review, and interview, the facility failed to ensure staff used enhanced barrier precautions during catheter care for 1 (#11) of 1 sampled resident reviewed for catheter care.The facility roster matrix showed four residents in the facility had urinary catheters. Findings:On 01/07/26 at 9:35 a.m., CNA #1 and CNA #2 were observed to provide urinary catheter care for Resident #11. The CNAs were observed to provide resident privacy, set up supplies, and don gloves. The CNAs were observed to provide catheter care without wearing a gown.An undated policy titled Enhanced Barrier Precautions, showed enhanced barrier precautions were needed for residents with a catheter to prevent the spread of infections, especially multidrug-resistant organisms in the facility. The policy showed gloves and gowns must be worn whenever touching the resident or their environment.A care plan, dated 12/05/25, showed Resident #11 had an indwelling catheter and was at risk for infection and complications related to catheter use and required enhanced barrier precautions to maintain…

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 record review and interview, the facility failed to ensure the results of an abuse investigation were submitted to the state within five business days for one (#1) sampled resident reviewed for abuse. The administrator identified 39 residents resided in the facility. Findings: An undated facility policy titled Policy: for reporting neglect and/or abuse, read in part, 1. Purpose: The purpose of this policy is to establish guidelines for reporting incidents of abuse and neglect in a long-term care facility, in compliance with state and federal regulations. Resident #1 had diagnosis which included mental disorder and was wheelchair bound. An Initial State Reportable Incident form, faxed 07/22/24 at 12:30 p.m., documented an allegation of abuse/mistreatment. It documented CNA #2 notified CNA #1 that Resident #1 had picked up their pizza box. CNA #1 grabbed Resident #1's wheelchair and spun them around and yelled in their face, and then again aggressively spun them around and pushed them from the table while being gruff and yelling at them. It documented cameras were in use at…

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 record review and interview, the facility failed to ensure an allegation of abuse was reported within 24 hours to OSDH of an incident of abuse for one (#1) of three sampled residents reviewed for allegations of abuse. The DON reported 38 residents resided in the facility. Findings: An incident report dated 06/03/24 at 2:57 p.m. CNA#1 reported alleged abuse occurred on 06/01/24. CNA #1did not report to LPN#1 until 06/02/24. On 06/06/24 at 4:15 p.m., CNA#1 stated the alleged abuse occurred on 06/02/24 at 6a.m. during the 11a.m.-7p.m. shift. The alleged abuse was reported on 06/02/24 11p.m. to 7a.m. shift to LPN #1 charge nurse. On 06/07/24 at 1:04 p.m., the Administrator reported CNA #1 witnessed an abuse on 06/01/24 and reported to LPN #1. On 06/02/24, the incident report was faxed on 06/03/24 at 2:57 p.m The 24 hours had exceeded.

Based on record review and interview, the facility failed to ensure that training was being provided for activities that contribute abuse/neglect, procedures for reporting incidents of abuse/neglect, and abuse prevention for one (#1) of one records records reviewed for abuse. The DON reported 38 residents reside in the facility. Findings: A Policy and Procedure: Training for Nurses and CNAs policy, undated, read in parts .Documentation will include dates and training, completion status, competency assessment results, and certificates of participation or completion .The Quality Assurance department will conduct periodic audits of training records to verify compliance with training . On 06/06/24 at 3:58 p.m., there was no documentation of CNA #1 of having abuse/neglect training of which includes reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property during CNA #1's orientation. On 06/07/24 at 1:06 p.m., the DON reported CNA #1 had no abuse/neglect training's completed during orientation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to submit PBJ FY Quarter 1 2024 ([DATE]-[DATE]) for direct care staffing based on payroll data. The administrator reported 38 residents resided in the facility. Findings: On 05/29/24 at 4:30 p.m., the administrator was asked about the PBJ report for the first quarter of 2024 ([DATE] - [DATE]). They reported it was not submitted within the required time frame. On 05/31/24 at 2:58 p.m., the administrator was asked about the facility's PBJ policy. They reported the policy was to complete them quarterly.

Based on record review and interview, the facility failed to develop, implement a policy and procedure for monitoring Legionella. The DON reported 38 residents resided in the facility. Findings: On 05/31/24 at 9:25 a.m., the maintenance director was asked to submit a specific policy for measures to prevent the growth of Legionella. They did not provide any descriptions of the water systems for visible inspection and/or steps to prevent the growth of Legionella in a flow diagram. On 05/31/24 at 9:15 a.m., ADON/IP reported there had not been any cases of Legionella. On 05/31/24 at 9:45 a.m., the administrator and DON were asked to the submit policy and procedures to include diagrams to identify areas of potential outbreaks of Legionella. The administrator reported they did not have a policy and procedure related to Legionella.

Based on record review and interview, the facility failed to ensure the resident assessment was transmitted within seven days of completion for one (#19) of one sampled resident reviewed for discharge assessments. The DON reported 38 residents resided in the facility. Findings: A Minimum Data Set (MDS), policy and procedure, not dated read in part, .Our facility is committed to ensuring the accurate and timely completion of the Minimum Data Set (MDS) for all residents, as required by federal and state regulations . On 05/30/24 at 9:30 a.m., the DON reviewed Res #19's MDS assessment. They reported there was a glitch in the system and the MDS coordinator did not receive a report that Res #19's MDS had not been submitted. They reported the MDS assessment was submitted yesterday. On 05/30/24 at 9:40 a.m., the DON notified the MDS coordinator on the phone via speaker. They reported they had a software issue with PCC. Reported they did not notice if it was on the report as accepted or rejected. They reported they modified the MDS because of the re-entry dates and transmitted the MDS…

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 interview, the facility failed to update the plan of care related to documented falls for two (#22 and #29) of five sampled residents reviewed for falls. The DON reported 38 residents resided in the facility. Findings: A Long Term Care Facility: Care Plan Policy and Procedure, not dated, read in part, .All residents will have a care plan that is resident-centered, addressing their medical, psychological, and social needs. Care plans will be developed, reviewed, and updated regularly in collaboration with residents, their families, and the interdisciplinary care team . Care interventions will be carried out as outlined in the care plan . A plan of care dated 12/12/23 through 06/12/23, documented, the resident is high risk for falls r/t Parkinson's disease. New Goal New Custom Goal: The resident will be free of falls through the review date. New Intervention: New Custom Intervention Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage…

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 record review and interview, the facility failed to ensure the medication was necessary to treat a specific condition indicated in the clinical record for three (#7, 14, and #31) of five residents reviewed for unnecessary medications. The DON reported 38 residents resided in the facility. Findings: An Antipsychotic Medication Policy and Procedure for Long-Term Care, not dated, read in part, .Assessment and Indication: Clinical Indication: Antipsychotic medications should only be prescribed for residents with a diagnosed psychiatric disorder (e.g., schizophrenia, bipolar disorder) or for the management of severe behavioral symptoms associated with dementia when other interventions have failed . A facility document titled, Psychosis/Schizophrenia/Behaviors, not dated, read in part, Antipsychotic's require specific diagnosis and behavior monitoring . Res #7's diagnosis included other recurrent depressive disorders, delusional disorders, generalized anxiety, and restlessness and agitation. 1. A physician's order as of 05/09/24 read in part, Ativan 0.5 mg give by mouth every 6…

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 and interview, the facility failed to ensure expired medications were removed from the medication storage room and from the medication cart. The Resident Census and Condition of Residents, dated 04/13/23, form documented 42 residents resided in the facility. Findings: On 04/13/23 at 9:00 a.m., during a tour of the medication room, two expired medications were observed. The medications included a bottle of Tums, for resident #36, with an expiration date of 7/22, and a bottle of Metformin 500 mg, in the Emergency Box, with an expiration date of 2/23. On 04/13/23 at 9:25 a.m., the medication cart was observed to have one expired medication, a bottle of Refresh eyes drops, for resident #7, expired 3/23. On 04/13/23 at 9:30 a.m., CMA #1 was asked how often staff checked for expired medications. The CMA stated, I haven't checked in about six months. On 04/13/23 at 10:00 a.m., the DON reported the pharmacist was supposed to be doing a check monthly for expired medications.

Based on record review, and interview, the facility failed to ensure a care plan was revised for fall interventions for one (#23) of four sampled residents reviewed for falls. The Administrator reported a facility census of 42 residents. Findings: Resident #23 was admitted with diagnoses which included hypertension and seizure disorder. A Quarterly MDS Assessment, dated 01/23/23, documented the resident was independent with ambulating and had two or more falls since admission. A nursing note, dated 12/01/22, documented the resident had a fall and was sent to the local hospital. The resident's seizure medication had been decreased. A nursing note, dated 12/01/22, documented the resident was moved to a room closer to the nurse's station .wheelchair in use. The resident was non-compliant with utilizing the call light for assistance. A nursing note, dated 12/01/22, documented a floor mat had been placed next to the bed in the lowest position .resident was found on the floor mat. A nursing note, dated 12/27/22, documented the resident's medication was adjusted and updated on the MAR. 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.