Colonial Park Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF585Jul 16, 2026

  Based on interview and record review, the facility failed to develop a grievance policy, appoint a grievance official, and maintain documentation of the results of all grievances. These deficient practices had the potential to affect all 68 residents who currently resided in the facility.Findings included: A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed the facility admitted Resident #21 on 06/22/2025. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. An annual MDS, with an ARD of 05/10/2026, revealed the facility admitted Resident #36 on 04/19/2019. […]

• No harm, potential for more than minimal, widespreadF880Jul 16, 2026

  Based on interview, facility policy review, and review of Occupational Safety and Health Administration (OSHA) guidance, the facility failed to ensure all staff were fit-tested for N95 respirator masks (masks used to protect residents and staff from the transfer of microorganisms that can cause infectious disease) prior to initial use and at least annually thereafter. This deficient practice had the potential to affect all 68 residents who resided in the facility. In addition, the facility failed to ensure a urinary catheter bag was not directly on the floor for 1 (Resident #64) of 1 sampled resident reviewed for catheter use.Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF880Mar 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were used: a. when transporting clean linens/laundry; b. when providing catheter care for 1 (#25) of 3 sampled residents who were reviewed for catheter care; and c. to devise and implement a plan to prevent the growth of and monitor for Legionella in the facility. The DON identified 68 residents who resided at the facility, four residents with catheters, and one resident with pressure ulcers. Findings: 1. On 03/26/25 at 9:47 a.m., laundry aide #1 was observed to return from delivering laundry/linens on north hall. During an observation of the laundry room the laundry aide stated they did not cover laundry/linens when they deliver them. […]

• No harm, potential for more than minimal, patternF689Nov 30, 2023

  Based on record review and interview, the facility failed to perform fall assessments after falls and initiate interventions to help prevent falls for one (#36) of three sampled residents reviewed for falls. The administrator identified 70 residents residing in the facility. Findings: An Assessing Falls and Their Causes policy, revised October 2010, read in parts, .Documentation .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment . A Falls Clinical Protocol policy, revised October 2010, read in part, .Treatment/Management .1. Based on the preceding assessment .the staff and physician will identify pertinent interventions to try to prevent subsequent falls .5. […]

• No harm, potential for more than minimal, isolatedF645Jul 16, 2026

  Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a serious mental illness diagnosis for 1 (Resident #10) of 1 resident reviewed for PASARR requirements.Findings included: An undated facility policy titled, Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability (PASARR), revealed, Purpose: Ensure each resident in a nursing facility is screened for a mental disorder (MD- also referred to as mental illness) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. […]