Colonial Manor Nursing Center

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three (Residents #2, #3, and #4) of 6 residents reviewed for abuse. On 01/05/2026 the facility failed to protect Resident #1 from hitting Resident #2 resulting in a scratch measuring 0.02x0.4cm to Resident #2's right eye and a scratch measuring 0.01x0.3cm to the bridge of Resident #2's nose. On 01/08/2026 the facility failed to protect Resident #4 from being called a liar by LVN A.On 01/31/2026 the facility failed to protect Resident #3 from being followed by Resident #1 down the hall to initiate a fist fight, residents' arms made contact with no injuries. This failure could place residents at risk of continued abuse and harm.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on Observations, interviews, and record review, the facility failed ensure residents had the right to be free from sexual abuse for 3 of 7 residents (RES #40, RES #18, and RES #27) who were investigated for sexual abuse. 1. The facility failed to stop RES #28 from having climbed into RES #18's bed and having sexually touched RES #18 penis on 9/7/2023, which prompted to a law enforcement investigation, a facility self-reported incident of Resident Abuse, with no care plan update for behaviors to protect residents from further abuse. RES #18's LAR expressed RES #18 had no known history of homosexual behaviors. 2. The facility failed to stop RES #18 from having reached out and having grabbed RES #27's left breast on 11/20/2023, which led to a facility self-reported incident of Resident Abuse with no care plan update for RES #18's behaviors to protect residents from further abuse. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop, update, and implement a comprehensive person-centered care plan for each resident, after four separate instances of resident abuse, that included measurable objectives and time frames to meet a resident medical, nursing, mental, and psychosocial needs for 2 of 7 residents (Resident #28 and RES #18) whose CPs were reviewed for regulatory compliance. The facility failed to update RES #28 and RES #18's CP after four separate incidents of sexual abuse: 1. The facility failed to update RES #28's CP after having climbed into RES #18's bed and having sexually touched RES #18 penis on 9-7-2023. 2. The facility failed to update RES #28's CP after having kissed RES #40 on 8-3-2023 and after having kissed RES #40 on 9-29-2023. 3. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.