Colonial Manor Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 4 med carts reviewed for food items stored on med carts and 2 of 4 residents (Resident #8, Resident # 84) reviewed for incontinence and infection control. CNA A while providing incontinent care for Resident #8, contaminated the whole packet of wet wipes by pulling out individual wipes from the packet with unclean gloves. LVN B failed to keep away his coffee tumbler containing coffee from the medication cart CNA A and CNA C entered Resident #84's room who was on contact isolations precautions without donning PPE when delivering and retrieving meal tray.CNA A exited Resident # 84's room from delivering meal tray and did not perform hand hygiene after exiting and prior to picking up the next meal tray for delivery.This failure could place the residents at the facility at risk of transmission of disease…

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 interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 4 residents (Resident #3) reviewed for reporting allegations of abuse. The facility failed to report a resident-to-resident altercation on 01/31/2026, when Resident #1 followed Resident #3 down the hall to initiate a fist fight, residents' arms made contact with no injuries. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.…

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 interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 4 residents (Resident #1) reviewed for self-determination. 1. The facility failed to ensure Resident #1's brief was changed when soiled when staff insisted she use the commode instead of her brief. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life.Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (neurological conditions that result from a stroke), transient…

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, interview and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #6, Resident #20, Resident #40, and Resident #42) reviewed for infection control. 1. MA C failed to properly sanitize the blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressures for Residents #6 and #20. 2. CNA A failed to wash or sanitize her hands while going from a dirty to clean surface while performing incontinent care on 02/05/25 at 9:20 AM for Resident #40. 3. LVN B failed to wash or sanitize his hands after removing a soiled dressing while performing wound care on Resident #42. These failures could place residents at-risk of cross contamination which could result in spreading infections or illness.…

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, interview, and record review, the facility failed to store food under sanitary conditions for 1 of 1 kitchens reviewed for dietary services. The facility failed to safely store food containers in the facility's only pantry, walk-in cooler, and freezer with labels to signify the date a product was open and a date to signify expiration. The facility failed to store food in properly sealed containers to prevent the growth of food borne pathogens. These failures could place residents at risk of exposure to food-borne pathogens. Finding include: Observations on 11/27/2023 at 8:56 AM of the facility's refrigerator revealed: 1 package of sliced luncheon meat stored in an unsealed plastic bag without the date it was opened or the date it expired; 2 slices of a pie stored in its original pie tin loosely covered without the date it was opened or the date it expired; 1 chicken breast in a plastic bag without the date it was opened or the date it expired; a plastic tub of beef without the date it was opened or the date it expired; 1 gallon BBQ sauce without the date it was…

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 make reasonable accommodation for residents to receive services in the facility for 3 of 6 residents (RES #18, RES #35, and RES #7) who were observed for access to facility services. The facility failed to ensure RES #18, RES #35, and RES #7 always had access to their individual call buttons. This failure could place residents at risk for unmet needs. Findings include: Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia (a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to 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, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for 1 (Resident #90) of 5 residents reviewed for baseline care plans. The facility failed to develop baseline care plans within the required 48-hour timeframe for Resident #90. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #90's face sheet dated 11/29/23 reflected Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses including dysphagia (difficulty in swallowing), muscle wasting and atrophy (when muscles waste away, hypertension (high blood pressure), and pneumonitis (lung inflammation due to inhalation of food and vomit). Review of the admission MDS dated [DATE] reflected Resident #90 had a BIMS score of 11 indicating Resident #90 was moderately cognitively impaired. Resident # 90 was dependent on staff for toileting…

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, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two of six residents (Residents #11 and #8) reviewed for respiratory care. A) The facility failed to ensure Resident #11's oxygen concentrator filter was clean, humidifier was dated, and tubing were dated. B) The facility failed to ensure Resident #8's oxygen concentrator filter was clean, humidifier was dated, and her oxygen tubing were dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of Resident #11's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems) Record review of Resident #11s quarterly MDS dated [DATE] reflected resident had a BIMS score of 15 showing she was…

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 reviews, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for quality of care, in that: The facility failed to assess and document complete neurological assessments for Resident #1 after he experienced unwitnessed falls on 08/15/2023, 08/29/2023, and 09/14/2023. This deficient practice could place residents at risk of pain, physical harm, and a diminished quality of life. Findings included: Review of Resident #1's face sheet, dated 09/21/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node), unspecified acute kidney failure, unspecified and other lack of coordination, difficulty in walking, history of falling, cognitive communication deficit, generalized muscle weakness, and…

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 reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 9 residents (Resident #5, Resident #7, and Resident #9) reviewed for call lights in that: Resident #5, Resident #7, and Resident #9 were observed in their rooms with call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Review of Resident #5's face sheet dated 8/18/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Hypertension (high blood pressure), Neuropathy (weakness, numbness, and pain from nerve damage), Chronic Obstructive Pulmonary Disease (breathing disorder), Dysphagia (difficulty swallowing), Anemia (low red blood cells), Hyperlipidemia (high cholesterol) and Cognitive Communication Deficit. Review of Resident…

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 observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation, in that: The facility failed to ensure a 50-pound bag of onions was stored properly in the dry storage area. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings include: During an observation on 8/18/2023 at 12:22 p.m., in the kitchen hallway leading to the outside, a 50-pound netted bag of yellow onions was seen sitting directly on the floor. The netted bag was on the floor and the floor was observed to have debris on it. The bag was propped up against a wall that had visible dirt on it as well as brown stains near the base and a rusty nail laying between the bag and the base of the wall. During an interview on 8/18/2023 at 12:22 p.m., the Dietary Manager was shown the bag of onions on the floor and stated, I know, I know. She stated they just had a truck come in earlier that…

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, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #4) reviewed for blood sugar checks. LVN A failed to appropriately sanitize her hands with ABHR and failed to appropriately clean Resident #4's finger with an alcohol pad before performing a blood sugar check. This failure could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization. Findings include: Review of Resident #4's face sheet dated 8/18/2023, reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Heart Disease, Hypertension (high blood pressure), Stroke, Chronic Kidney Disease, Hyperlipidemia (elevated levels of cholesterol), Anemia (low red…

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.