Colonial Manor Nursing Home

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of abuse was reported timely to the State Survey Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse. In addition, the facility's Abuse Prevention Policy contained outdated reporting requirements that were inconsistent with current federal regulations and did not provide staff with accurate direction regarding required State Agency reporting timeframes.

Inspectors wroteBased on interview and document review, the facility failed to implement immediate protective measures for resident protection after staff witnessed a co-worker subject 1 of 1 resident (R1) to alleged abuse in the form of derogatory verbiage and actions that caused R1 to fall backwards onto the bed. As a result of this failure, the alleged perpetrator continued to provide care to R1, along with other residents, for approximately four hours after the witnessed allegation with the potential to affect all residents who resided in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to have a registered nurse (RN) on duty 8 consecutive hours a day, 7 days a week for 3 of 18 days reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department in the absence of a full time dietitian. This had the potential to affect all 26 residents, visitors and staff who consumed food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen with appropriately clean food preparation equipment identified as a buildup of dust and grease on exhaust vents and food residue on food preparation equipment. This had the potential to affect all 26 residents who received food prepared in the facility kitchen.

Inspectors wroteThe facility failed to submit accurate staffing information for payroll-based journal (PBJ) for 1 of 4 quarters (quarter 4) reviewed.

Inspectors wroteBased on interview and document review the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee for improvements had a developed measurable goal, action plan identified to reach the goal and analysis of the data collected on the improvement activities. This had the potential to affect all 26 residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure the infection preventionist (IP) brought a thorough report to the Quality Assurance Performance Improvement (QAPI) meetings on the infection control program.

Inspectors wroteBased on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness dependent upon their symptoms for 3 of 3 months reviewed. This has the potential to affect all 26 residents who resided at the facility. Review of the facility staff illness surveillance identified the following1. On 10/13/25 licensed practical nurse (LPN)-A called in for his shift with symptoms of glassy eyes, sore throat, and feeling sick. The surveillance did not identify the last day worked, the date symptoms resolved, or when LPN-A returned to work.2. On 10/20/25 nursing assistant (NA)-A called in with symptoms of a sore throat and a temperature of 100.1. Her last day worked was 10/19/25. The staff illness log did not identify when NA-A was eligible to return to work or her actual return to work date. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's interim director of nursing (IDON)) had completed specialized training in infection prevention and control. This had the potential to affect all 26 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 3 of 3 residents (R3, R4, and R16). This deficient practice had the potential to affect all 26 residents who resided in the facility.

Inspectors wroteBased on interview and document review the facility failed to provide timely beneficiary notice to 1 of 3 (R31) sampled residents.

Inspectors wroteBased on interview and document review the facility failed to have a discharge summary for 1 of 1 (R31) sampled residents.

Inspectors wroteBased on observation, interview and document review the facility failed to prevent potential accident hazards for 1 of 1 resident (R5) due to wandering behaviors into an unsecured area with steep cement stairs down to a cement floor.

Inspectors wroteBased on observation, interview and document review the facility failed to include the facility census in their daily posting of nursing staff for 29 of 29 days reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 sampled residents (R6, and R14) were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).

Inspectors wroteBased on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 25 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on interview and document review the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 25 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance for 4 of 5 residents (R9, R19, R20, R25) reviewed for antibiotics. This had the potential to affect any of the 25 residents who resided in the facility who might use antibiotics.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow their grievance process for missing personal property for 1 of 1 resident (R19) who reported missing property.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of abuse were reported to the administrator and the State Agency (SA) timely for 1 of 1 resident (R24) reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure a residents hospice status was accurately coded on the Minimum Data Set (MDS) assessment for 1 of 1 residents (R15) reviewed for hospice and end of life.

Inspectors wroteBased on interview and document review, the facility failed to ensure a care plan was revised to include hospice care for 1 of 1 residents (R15) reviewed for hospice and end of life.

Inspectors wroteBased on interview and document review, facility failed to document a complete recapitulation of stay for 1 of 1 resident (R28) reviewed for discharge.

Inspectors wroteBased on observation, interview and document review, the facility failed to document and monitor weight loss for 1 of 1 resident (R24) who had weight loss. In addition, the facility failed to obtain accurate weights for 2 of 2 residents (R24, R4) who were evaluated for nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R26) who had a urinary ostomy

Inspectors wroteBased on interview and document review the facility failed to have records of the pneumococcal vaccinations for 1 of 1 resident (R19) and the influenza vaccine for 2 of 3 residents (R19, and R7) reviewed for immunization protocol for who had a signed agreement to receive the influenza vaccine. In addition, the facility failed to document for 1 of 1 resident (R19), the influenza vaccine had been offered and education on risks/benefits was completed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure sufficient staffing was available to provide timely assistance with personal cares needs for 7 of 7 residents (R1, R2, R3, R4, R5, R6, and R7) who voiced concerns of inadequate number of staff to routinely meet their needs in a timely manner

Inspectors wroteBased on observation, interview and document review the facility failed to revise the care plan for 1 of 1 resident (R1) who had a change with activities of daily living (ADL's).

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess, monitor, develop and implement person centered interventions to prevent a pressure ulcer for 1 of 3 residents (R1) reviewed who entered the facility without a pressure ulcer.

Inspectors wroteBased on observation, interview, and document review the facility failed to develop an individualized toileting program to maintain or improve bowel/bladder continence resulting in a decline in continence for 1 of 1 residents (R1) reviewed for incontinence.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and sanitary environment in the kitchen when general cleaning had not been done and when personal items belonging to staff where observed in food prep areas. In addition, 2 of 2 fans in the kitchen were observed with dust and debris, blowing on clean dishes, a food prep (preparation) surface, a convection oven, and an industrial oven/stove. This had potential to affect all 27 residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide supervision for a 1 of 3 residents (R9) who was diagnosed with Alzheimer's disease and has a history of roaming and elopement.