Colonial Manor Nursing & Rehabilitation Home

In the surveyor’s words

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

• Actual harm, isolatedF600Sep 25, 2024

  Based on observation, record review and interviews, the facility failed to protect the residents' right to be free from verbal and physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for resident #1, who was cognitively impaired, on 08/26/2024 at 2:28 a.m. when S4 Certified Nursing Assistant (CNA) was observed being verbally and physically abusive to resident #1 while providing care. Resident #1's family member observed S4CNA being verbally and physically abusive to resident #1 while reviewing video surveillance camera footage. […]

• Actual harm, isolatedF600Feb 27, 2024

  Based on record reviews and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. The actual harm resulted for resident #1, who was severely cognitively impaired, being sexually assaulted by resident #2. On 02/19/2024 at 9:15 p.m. S3CNA (Certified Nursing Assistant) witnessed resident #2 standing at the bedside of resident #1. Resident #2 had his penis in the mouth of resident #1. […]

• No harm, potential for more than minimal, widespreadF812Jan 7, 2026

  Based on observations and interviews, the facility failed to: 1.) ensure proper hair restraint for kitchen staff and 2.) store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect 57 residents that received meals prepared in the facility's kitchen. Findings:Review of the undated facility's date marking for food safety policy revealed in part, the following:-The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.-The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.-The marking system shall consist of a label and the day/date of opening.-The discard day or date… […]

• No harm, potential for more than minimal, widespreadF814Jan 7, 2026

  Based on observations and interviews, the facility failed to ensure garbage had been disposed of properly. The facility census was 58 residents and the deficient practice had the potential to affect all residents.Findings:Review of the facility's Disposal of Garbage and Refuse policy undated revealed in part,:-Garbage and refuse containers shall be durable, cleanable, and free from crack or leaks and covered when not in use.-Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. […]

• No harm, potential for more than minimal, widespreadF908Jan 7, 2026

  Based on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the three torn door seals on three individual refrigerator doors of one refrigerator, one broken toaster, one toaster missing a crumb catcher, two of the three toasters were stored and full of bread crumbs, four full size pans covered in a black hardened substance, four half pans covered in a black hardened substance, two ovens covered with hardened black substance, one oven with four silver pieces of material approximately the size of a golf ball and a microwave with dark splattered substance on top and sides.Findings:Observation of the kitchen during the initial tour on 01/05/2026 at 7:55 a.m. […]