Colonial Manor Nursing & Rehabilitation Home

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure CNAs have the specific competencies, and skill sets necessary to care for resident needs by not wearing appropriate PPE when providing care to a resident on EBP for 1 (#5) of 5 residents reviewed for competent nursing staff.

Inspectors wroteBased on observations and interviews, the facility failed to: 1.) ensure proper hair restraint for kitchen staff and 2.) store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect 57 residents that received meals prepared in the facility's kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage had been disposed of properly. The facility census was 58 residents and the deficient practice had the potential to affect all residents.

Inspectors wroteBased on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the three torn door seals on three individual refrigerator doors of one refrigerator, one broken toaster, one toaster missing a crumb catcher, two of the three toasters were stored and full of bread crumbs, four full size pans covered in a black hardened substance, four half pans covered in a black hardened substance, two ovens covered with hardened black substance, one oven with four silver pieces of material approximately the size of a golf ball and a microwave with dark splattered substance on top and sides.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#39 and #46) of 2 sampled residents reviewed for environmental concerns. The facility failed to ensure:1. Resident #39's air conditioning/heating unit was kept clean;2. Resident #46's sink faucet remained in good repair.

Inspectors wroteBased on observation, record review and interviews, the facility failed to report an injury of unknown origin to the State Agency no later than 24 hours in accordance with State law for 1 (#55) of 1 resident reviewed for abuse.

Inspectors wroteBased on observation, record review and interviews, the facility failed to investigate an injury of unknown origin for 1 (#55) of 1 resident reviewed for abuse.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure an infection prevention and control program was maintained to help prevent the development and transmission of communicable diseases and infections for 4 (#5, #7, #17, #20) of 4 residents reviewed for infection control. The facility failed to ensure:1. EBP precautions were followed during catheter care (#5);2. Infections control procedures followed during wound care (#7);3. A syringe was stored properly after staff provided PEG care (#20); and4. An EBP sign was placed on a resident's door (#17)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have the right to be free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. The facility failed to ensure a PRN order for a psychotropic medication was limited to 14 days for 1 (#2) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review and interview the facility failed to update the plan of care for 1 (#55) of 1 resident reviewed for an injury of unknown origin.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the physician and family were notified after a resident's fall for 1 (#1) of 1 resident reviewed for falls.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to document a post fall assessment and complete an incident report as stated in the facility's fall prevention program policy for 1 (#1) of 1 residents reviewed for accidents that experienced a fall.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#20) of 1 (#20) resident reviewed for restraints.

Inspectors wroteBased on observation, interviews and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 (#41) of 1 residents reviewed for anticoagulants.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident enviornment remained as free of accident hazards as possible by failing to ensure resident rooms maintained a water temperature of less than 120 degrees for 4 (#19, 37, 41, 66) of 4 residents whose rooms were assessed for water temperatures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#4) of 3 (#1, #4, #43) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device as ordered for the resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections by failing to implement its policy for enhanced barrier precautions for 1 (#37) of 1 residents reviewed for transmission based precautions.

Inspectors wroteBased on observation, record review and interviews, the facility failed to protect the residents' right to be free from verbal and physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for resident #1, who was cognitively impaired, on 08/26/2024 at 2:28 a.m. when S4 Certified Nursing Assistant (CNA) was observed being verbally and physically abusive to resident #1 while providing care. Resident #1's family member observed S4CNA being verbally and physically abusive to resident #1 while reviewing video surveillance camera footage. [...]

Inspectors wroteBased on observation and interviews, the facility failed to treat each resident with respect and dignity in a manor and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. This failed practice occurred when S4Certified Nursing Assistant (CNA) did not assist resident #1 to the restroom after resident #1 requested to go to the restroom.

Inspectors wroteBased on record review and interviews, the provider failed to ensure an alleged violation involving verbal and physical abuse that was reported to the Administrator by resident #1's family member was reported immediately, but no later than 2 hours after being made aware, to the State Survey Agency in accordance with State Laws for 1 (#1) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. The actual harm resulted for resident #1, who was severely cognitively impaired, being sexually assaulted by resident #2. On 02/19/2024 at 9:15 p.m. S3CNA (Certified Nursing Assistant) witnessed resident #2 standing at the bedside of resident #1. Resident #2 had his penis in the mouth of resident #1. Because this type of unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's condition would have experienced severe psychosocial harm, dehumanization and humiliation as a result of the non-consensual sexual contact.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 2 (#1 and #42) of 6 (#1, #6, #36, #42, #53, and #54) sampled residents investigated for accidents. The facility failed to implement new interventions after residents #1 and #42 were identified as having a fall.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a comprehensive person-centered care plan was implemented for 1 (#56) of 1 (#56) residents investigated for pressure ulcers. The facility failed to ensure resident #56 had a pressure relieving device in the seat of his wheelchair, as he was at risk for pressure ulcers and dependent upon the wheelchair for his mobility.

Inspectors wroteBased on record review and interviews, the facility failed to conduct regular inspections of all bed rails for 1 (#53) of 6 (#1, #6, #36, #42, #53, and #54) residents investigated for accidents. The facility failed to identify that resident #53's bed rail was not properly secured to the resident's bed.