Colonial Manor II

In the surveyor’s words

From the most serious findings on record at Colonial Manor II, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 17, 2023

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to perform neuro checks as ordered by the physician, and to notify the physician with a change of condition per the facility's Neuro Checks Policy and Procedure. The resident passed away that night. On [DATE] at 1:05 a.m., Resident #43 had a fall and reported to the nurse he had hit his head and complained of pain all over. The resident was sent to the ER per physician orders. The hospital record documented the resident fell backwards and was complaining of a headache. The resident was given pain medication and sent back to the facility with orders to do neuro checks every two hours for 24 hours. […]

• Immediate jeopardy, isolatedF689Jun 17, 2021

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 05/26/21 related to the facility's failure to provide adequate supervision to ensure a resident remained safe and free from elopement. The facility failed to provide adequate supervision to resident which resulted in him getting out of the facility unattended. The resident remained off the premises all night during a rain storm. On 06/17/21 at 3:05 p.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to protect the resident and prevent elopement. […]

• No harm, potential for more than minimal, widespreadF851Jun 1, 2024

  Based on record review and interview, the facility failed to submit PBJ FY Quarter 1 2024 ([DATE]-[DATE]) for direct care staffing based on payroll data. The administrator reported 38 residents resided in the facility. Findings: On 05/29/24 at 4:30 p.m., the administrator was asked about the PBJ report for the first quarter of 2024 ([DATE] - [DATE]). They reported it was not submitted within the required time frame. On 05/31/24 at 2:58 p.m., the administrator was asked about the facility's PBJ policy. They reported the policy was to complete them quarterly.

• No harm, potential for more than minimal, widespreadF880Jun 1, 2024

  Based on record review and interview, the facility failed to develop, implement a policy and procedure for monitoring Legionella. The DON reported 38 residents resided in the facility. Findings: On 05/31/24 at 9:25 a.m., the maintenance director was asked to submit a specific policy for measures to prevent the growth of Legionella. They did not provide any descriptions of the water systems for visible inspection and/or steps to prevent the growth of Legionella in a flow diagram. On 05/31/24 at 9:15 a.m., ADON/IP reported there had not been any cases of Legionella. On 05/31/24 at 9:45 a.m., the administrator and DON were asked to the submit policy and procedures to include diagrams to identify areas of potential outbreaks of Legionella. […]

• No harm, potential for more than minimal, patternF698Jan 8, 2026

  Based on observation, record review, and interview, the facility failed to assess and monitor a resident before and after dialysis treatments for 1 (#4) of 1 sampled resident reviewed for dialysis.The administrator identified one resident required dialysis services. Findings: On 01/06/26 at 3:20 p.m., Resident #4 pulled up their sleeve and showed the dialysis shunt site on their left forearm to this surveyor. An undated policy titled Dialysis, showed nursing staff would monitor residents before and after dialysis, and dialysis access sites would be protected and observed for signs of infection or complications. The policy showed all dialysis-related care, observations, and communications would be documented in the resident's medical record. […]