Colonial Manor Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Dec 23, 2023

  Based 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. […]

• Immediate jeopardy, patternF656Dec 23, 2023

  Based 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. […]

• Actual harm, isolatedF600Feb 13, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Dec 23, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 4 med carts reviewed for food items stored on med carts and 2 of 4 residents (Resident #8, Resident # 84) reviewed for incontinence and infection control. CNA A while providing incontinent care for Resident #8, contaminated the whole packet of wet wipes by pulling out individual wipes from the packet with unclean gloves. […]