Colonial Manor of Elma

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 9, 2026

  Based on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure one of six residents reviewed remained free from a resident to resident physical altercation when a resident with severe cognitive impairment and a known history of aggressive behaviors (Resident #6) hit another resident (Resident #2). Three of six residents reviewed experienced fear from the Resident #6's aggressive behavior (Resident #2, Resident #4, and Resident #5). Resident #2 experienced increased anxiety, social isolation, a decline in nutritional intake, and fear following the incident. Resident #4 and Resident #5 expressed fear of Resident #6 and reported decreased activity participation due to Resident #6's behaviors. […]

• Actual harm, isolatedF689Dec 5, 2024

  Based on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to provide a full assessment for 1 of 4 residents sampled for falls (Resident #2). Resident #2 fell on [DATE] at 9:50 PM. Resident #2 exhibited left hip pain and an externally rotated left leg. Staff A, Assistant Director of Nursing (ADON) failed to assess the resident and assisted Resident #2 from the floor to standing position where Resident #2 could not bear weight on his left leg. Staff A called for help and Staff B, Certified Nursing Assistant (CNA) assisted her to transfer Resident #2 into a wheelchair and then they transferred him to lay in bed. Resident #2 was transferred to the emergency room department on 10/13/24. […]

• No harm, potential for more than minimal, patternF801May 2, 2024

  Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 35 residents. Findings include: During an interview on 4/29/24 at 9;50 AM, the Dietary Manager reported the facility is working on getting her enrolled in the dietary manager classes. During an interview on 4/30/24 at 10:42 AM, the Consultant Dietician reported the Dietary Manager is not certified but currently in the course. She reported when she is in the building it varies when she comes but reviews the residents at least once a week. […]

• No harm, potential for more than minimal, isolatedF602Feb 19, 2026

  Based on record review, staff interviews, and policy review the facility failed to protect 1 of 2 resident's rights to be free from misappropriation of their opioid pain medication patches (fentanyl) (an extremely potent, synthetic (lab-made) opioid used for pain) (Resident #42). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 documented a Brief Interview for Mental Status (BIMS) of 9, indicating moderate cognitive impairment. The MDS included diagnoses of low back pain, age related osteoporosis, and limitation of activities due to disability. […]

• No harm, potential for more than minimal, isolatedF605Feb 19, 2026

  Based on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #35). The facility identified a census of 36.Findings include:Resident #35's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00, indicating a severe cognitive loss. The MDS listed diagnoses of non-Alzheimer's dementia and anxiety. The MDS reflected Resident #35 used an anti-anxiety medication during the lookback period. […]