Colonial Manor Advanced Rehab & Healthcare

In the surveyor’s words

From the most serious findings on record at Colonial Manor Advanced Rehab & Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 16, 2025

  Based on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision.CNA A did not follow 2-person assist as stated on Resident #1's care plan when providing incontinent care and repositioning on two separate occasions on [DATE] at around 12:00am and 1:00am. On [DATE] at 3:30am CNA A found Resident #1 on the floor. Resident #1 was sent to the hospital and later expired on [DATE].An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:51pm. […]

• Immediate jeopardy, isolatedF580Aug 17, 2023

  Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status due to medication error for one (Resident #7) of three residents reviewed for resident rights. The facility failed to notify Resident #7's physician in a timely manner when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate on 01/10/2023. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility Administrator on 08/11/2023 at 7:23 PM. […]

• Immediate jeopardy, isolatedF689Aug 17, 2023

  Based on observation, interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 resident (R#4) of 7 residents reviewed for accidents, in that: Registered Nurse (RN E) and Certified Nurse Assistant (CNA D) failed to use a mechanical lift to transfer R#4 resulting in R#4 sustaining a left femoral fracture. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/03/2023 and ended on 03/09/2023. The facility corrected the non-compliance before the investigation began. […]

• Immediate jeopardy, isolatedF755Aug 17, 2023

  Based on interview and record review the facility failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #9, and Resident # 10) being reviewed for pharmacy services. Facility did not ensure that narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversion. An Immediate Jeopardy was identified on 08/13/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 6:54 p.m. […]

• Immediate jeopardy, isolatedF760Aug 17, 2023

  Based on interviews and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #7) of 3 residents reviewed for medication errors in that: The facility did not follow physician's orders for Resident #7 when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 7:23 PM. […]