Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Of Elma during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, hallucinations, delusions, and a documented pattern of physical and verbal aggression was allowed to ambulate freely and repeatedly exhibit disruptive and threatening behaviors toward others without behavior‑specific care plan interventions. This resident ultimately slapped another cognitively intact resident on the upper arm in a hallway confrontation, causing pain and a red mark, after staff were unable to separate them in time. Following this event, the assaulted resident, who had a history of anxiety and depression, reported increased anxiety, fear of being hit again, social withdrawal to her room, use of headphones during meals to block out the aggressive resident’s outbursts, and reduced meal intake, while staff observed her crying and avoiding interaction. Two other cognitively intact residents also reported being scared of the aggressive resident, limiting their time out of their rooms and declining activities due to her yelling, screaming, and perceived risk of being hit. Staff interviews and documentation confirmed that the aggressive resident’s behaviors had worsened over months, that other residents were fearful, and that the care plan did not include interventions for the known aggressive behaviors, despite an abuse policy prohibiting physical abuse such as hitting and slapping by other residents.
A resident with moderate cognitive impairment and chronic pain had an active order for fentanyl 25 mg patches when staff later discovered two patch packages in the resident’s supply that were empty, appeared cut open, and had been taped shut and returned to the box. Facility investigation records identified this as medication diversion involving the resident’s fentanyl patches, meaning the ordered opioid patches were removed from their packaging without the resident’s consent, resulting in misappropriation of the resident’s medication.
Failure to document non-pharmacological interventions before PRN lorazepam administration. A resident with severe cognitive loss, dementia, and anxiety had a PRN order for lorazepam for anxiety/restlessness, and the care plan directed staff to try measures such as 1:1 interaction, hydration, snacks, music, toileting, and other calming interventions before giving psychotropic meds. Progress notes and the psychotropic med review did not document those interventions before multiple PRN doses, and staff interviews confirmed the missing documentation.
Incorrect PASRR Level II Coding on MDS Assessments: The facility inaccurately coded 2 MDS assessments for residents with PASRR Level II outcomes. One resident had diagnoses including anxiety, depression, bipolar disorder, and schizophrenia, and another resident had moderate cognitive impairment on BIMS; however, both records showed PASRR Level II approval for mental illness, and the MDSs incorrectly indicated no Level II PASRR serious mental illness and/or intellectual disability or related condition.
A resident with diagnoses including anxiety, depression, bipolar disorder, and schizophrenia had a PASRR directing specialized services in the form of a behavior management plan for anxiety/worry, verbal aggression, irritability, and anger-related communication. However, the care plan lacked a behavior management plan, and the DON confirmed none was in place.
A resident with bowel and bladder incontinence, renal failure, DM, and recent UTI treatment received improper incontinent care when a CNA used soiled gloves to handle a clean brief and then fastened it without hand hygiene. The DON observed the error, and the resident’s care plan noted frequent UTIs and peri-care twice daily, but did not include EBP direction.
Failure to obtain ordered daily weights and report significant weight gains. A resident with severe cognitive impairment, aphasia, metabolic encephalopathy, and acute respiratory failure had a provider order for daily weights and notification for weight gains over 3 lb in a day, but the EHR showed multiple missing daily weights and 3-lb gains that were not documented as reported to the MD. The DON said daily weights had been started because of unexplained edema, and the Administrator said staff were expected to obtain and enter the weights daily.
Improper medication handling during a med pass: a CMA failed to perform hand hygiene and repeatedly touched medication cards, cart surfaces, and stock bottles with bare hands or gloves before preparing and administering meds to three residents. The DON, an LPN, and another CMA stated hand hygiene should occur between residents, and the facility policy directed hand hygiene before and after each resident’s med pass and said meds should not be touched.
A resident with severe cognitive impairment and a history of falls did not have a care plan intervention—a chair alarm—implemented as required. Staff observed the resident stand up and fall from a wheelchair, and multiple staff members confirmed the chair alarm was not in place at the time, despite facility policy and the care plan specifying its use.
A resident with intact cognition reported that a CNA used offensive language in her presence, speaking derogatorily about an LPN. The CNA admitted to the behavior, which was confirmed by the LPN and other staff. The facility's policy on dignity and respect was violated, as staff are expected to provide considerate and respectful care.
The facility failed to follow CDC guidelines for Enhanced Barrier Precautions during catheter care for three residents, leading to a deficiency in infection prevention and control. Staff did not use isolation gowns as required, and there was a lack of proper signage and PPE availability. The Director of Nursing confirmed the need for EBP for residents with urinary catheters, but issues with staff awareness and equipment availability were evident.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS within 14 days for a resident who elected hospice care. The resident, with severe cognitive loss and multiple diagnoses, was signed into hospice care, but the MDS lacked documentation of hospice services. The MDS Coordinator was aware of the hospice admission but missed setting up the SCSA MDS, and the DON expected adherence to RAI guidelines.
A resident with a history of lower extremity impairment fell and was improperly assisted to a standing position by the ADON without a full assessment, leading to a diagnosis of a hip fracture. The ADON admitted to not performing a proper assessment and altering documentation. The facility had recently discontinued fall alarms, raising concerns from the resident's family.
The facility failed to ensure that the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The Dietary Manager was in the process of enrolling in dietary manager classes, and the Consultant Dietician confirmed that the manager was not yet certified. The employee file lacked documentation of a certificate of completion for the Dietary Manager courses.
The facility failed to follow physician orders for a resident with benign prostatic hyperplasia, anxiety, and hypertension. Despite a physician order for a Urology referral, no appointment was scheduled, and there was no documentation of any call to Urology. The DON confirmed the lapse and noted the absence of a policy for handling physician orders.
The facility failed to conduct proper assessments for a resident with impairments in both upper and lower extremities to determine if she remained at baseline or had experienced a decline in ROM and mobility. Staff acknowledged the resident's refusals for restorative care but did not document ongoing assessments or conduct a new therapy screen during the annual review as required.
Failure to Protect Residents From Aggressive Resident Leading to Abuse and Fear
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to implement appropriate care plan interventions for a resident with severe cognitive impairment and escalating aggressive behaviors, which resulted in a resident‑to‑resident physical altercation and fear among multiple residents. One resident with non‑Alzheimer’s dementia, severe cognitive impairment (BIMS scores of 2/15 and later 1/15), hallucinations, delusions, and documented physical and verbal aggression toward others repeatedly exhibited behaviors such as hitting, grabbing, scratching, threatening, wandering, entering other residents’ rooms, and attempting to elope. Despite a Significant Change MDS that identified these behaviors and documented that they significantly intruded on others, the resident’s plan of care contained focus areas for impaired cognition, elopement/wandering risk, and psychotropic medication use, but lacked behavior‑specific interventions addressing the aggressive and intrusive behaviors recorded on the MDS and in multiple behavior notes. Point of Care and nursing documentation throughout March detailed numerous episodes in which this cognitively impaired resident was physically and verbally aggressive toward staff and residents, including grabbing and hitting others, cursing, threatening to hurt people with objects, attempting to enter other residents’ rooms, and causing disruption in common areas. Notes described the resident as very difficult to redirect, verbally violent and threatening, talking about using a “2 by 4” to “woop” people, attempting to elope multiple times, trying to get into the kitchen and out fire doors, and waving a fork aggressively while threatening to hit staff. Staff documented that other residents did not want this resident near them due to her confusion, nonstop talking, physical closeness, and disruptive behaviors. A housekeeper and CNAs confirmed that the resident independently ambulated throughout the facility and displayed hitting, kicking, throwing items, and frequent verbal outbursts during meals and activities. On one occasion, this aggressive resident confronted two other residents in a hallway after misunderstanding their conversation. Staff attempted to separate them, but the aggressive resident slapped another resident on the left upper arm with an open hand while yelling and being combative with staff, causing a red mark and pain at the time of the incident. The assaulted resident, who had intact cognition and a history of anxiety, depression, and adjustment disorder, reported discomfort around loud and aggressive individuals and subsequently described increased anxiety about being around the aggressive resident, fear of being hit again, and a preference to stay in her room or wear headphones during meals to drown out the other resident’s outbursts. Documentation showed that after the incident, this resident spent more time isolated in her room, came out mainly for meals, avoided eye contact, cried due to fear, and had reduced nutritional intake compared to earlier in the month. Two additional cognitively intact residents also reported fear related to the aggressive resident’s behaviors. One resident stated she witnessed the hallway incident in which the aggressive resident hit another resident on the shoulder/upper arm and threatened to hit harder, and reported being scared and now only coming out for meals, no longer attending activities as before. She kept her room door open so she could see if the aggressive resident attempted to enter and stated she would chase her out if needed. Another resident reported being scared of the aggressive resident, describing that the aggressive resident would yell and scream during activities and meals and would “hit anyone,” leading her to avoid coming out for activities. Multiple CNAs and an LPN corroborated that these residents were fearful, cried in their rooms, came out only for meals or small groups, and declined activities due to fear of the aggressive resident. The facility’s abuse prevention policy stated that residents must not be subjected to abuse by anyone, including other residents, and defined physical abuse as hitting, slapping, and similar acts, yet the documented pattern of aggressive behavior and the lack of corresponding care plan interventions contributed to an environment in which one resident physically struck another and several residents experienced ongoing fear. A registered nurse acknowledged that the facility did not put interventions in place after the physical altercation and that the plan of care lacked interventions for the behaviors identified on the Significant Change MDS. The primary care physician for the assaulted resident later confirmed that they became aware of the incident through round‑table discussions and that the resident reported anxiety about going to the dining room and being around large groups following the event. Throughout this period, observations showed the fearful residents remaining in their rooms with doors closed or only briefly attending meals or limited activities, often wearing headphones and avoiding interaction, while the aggressive resident continued to ambulate freely, enter common areas, and assert that the facility belonged to her and that she would make others do what she said. These documented actions and omissions demonstrate that the facility did not ensure residents were free from abuse by other residents and did not adequately address known aggressive behaviors through individualized care planning and effective supervision. The facility’s own Abuse, Prevention, Reporting and Investigation Policy stated that residents must be free from abuse, including physical abuse such as hitting and slapping, and that residents must not be subjected to abuse by other residents. Despite this, the aggressive resident’s repeated physical and verbal behaviors toward others, the lack of corresponding care plan interventions, and the subsequent physical striking of another resident in the hallway show a failure to protect residents from abuse. The resulting fear, anxiety, social withdrawal, and decreased participation in activities and meals among multiple residents were documented by residents, staff, and clinical notes, all occurring in the context of the facility’s failure to implement behavior‑specific interventions for a resident with a clearly documented pattern of aggression and intrusion on others. Staff interviews further supported that the aggressive resident’s behaviors had worsened over the prior months and that other residents were fearful and scared. Housekeeping and CNA staff described residents crying in their rooms, expressing that they did not feel able to leave due to fear of being hit, and altering their daily routines to avoid contact with the aggressive resident. Observations by surveyors of residents remaining in their rooms with doors closed, wearing headphones, and avoiding eye contact aligned with these reports. Collectively, the documented behaviors, the absence of care plan interventions addressing those behaviors, the physical altercation, and the resulting psychosocial impact on multiple residents form the basis of the deficiency related to failure to protect residents from abuse and to maintain an environment free from resident‑to‑resident physical aggression. The facility census at the time was 32 residents, and six residents were reviewed, with one resident identified as the aggressor and three residents identified as experiencing fear related to that resident’s behaviors. The aggressive resident’s MDS and behavior documentation clearly showed severe cognitive impairment, psychotic symptoms, and a pattern of physical and verbal aggression that significantly intruded on others, yet the plan of care did not reflect interventions to manage these behaviors. This gap, combined with ongoing documentation of aggressive incidents and staff acknowledgment that interventions were not implemented after the physical altercation, directly contributed to the deficiency in protecting residents from abuse as required by facility policy and regulatory standards.
Failure to Protect Resident from Misappropriation of Fentanyl Patches
Penalty
Summary
The facility failed to protect a resident’s property by not preventing the misappropriation of the resident’s prescribed opioid pain medication patches. The resident had moderate cognitive impairment, with a BIMS score of 9, and diagnoses including low back pain, age-related osteoporosis, and limitation of activities due to disability. Her MDS documented opioid use, and her physician’s orders and EHR reflected an active order for a 25 mg fentanyl patch over a specified period. During this time, staff later identified that two fentanyl patch packages associated with this resident were found empty, with the packages appearing to have been cut open, the patches removed, and the packages placed back into the box and taped shut. The facility’s own investigation documentation, titled as a criminal act and medication diversion investigation, confirmed that on a specific date an RN discovered the two empty fentanyl patch packages that appeared tampered with. This discovery led to the determination that the resident’s fentanyl patches were missing from their packaging, indicating misappropriation of the resident’s medication. The facility’s abuse prevention, reporting, and investigation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a patient’s belongings or money without consent, and required immediate measures upon receiving such a report. The events described show that the resident’s ordered fentanyl patches were wrongfully removed from their packaging without the resident’s consent, constituting misappropriation of the resident’s belongings.
Failure to Document Non-Pharmacological Interventions Before PRN Lorazepam
Penalty
Summary
The facility failed to document non-pharmacological interventions before administering PRN lorazepam for anxiety and restlessness to one resident with severe cognitive loss. Resident #35 had diagnoses of non-Alzheimer's dementia and anxiety, and the MDS showed a BIMS score of 00. The resident had an order for lorazepam 0.5 mg, 0.5 tablet by mouth every 2 hours as needed for anxiety/restlessness, and the care plan identified use of an anti-anxiety psychotropic medication related to agitation and anxiety. The resident's care plan intervention directed staff to attempt non-pharmacological measures before giving psychotropic medications, including one-to-one interaction, hydration, snacks, television, music, toileting, going outside, hand massage, gentle touch, shoulder rub, deep breathing, family visits, and phone calls. However, the psychotropic medication monthly review lacked documentation of these interventions, and progress notes showed multiple PRN lorazepam administrations without documentation that non-pharmacological interventions were attempted first. Staff interviews confirmed that the required interventions were not documented in the progress notes for most of the January 2026 administrations.
Incorrect PASRR Level II Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code 2 of 2 MDS assessments for residents with PASRR Level II outcomes. Resident #4’s MDS, dated [DATE], indicated she did not have a state Level II PASRR serious mental illness and/or intellectual disability or related condition, even though her record included diagnoses of anxiety, depression, bipolar disorder, and schizophrenia. Her MDS also documented a BIMS score of 15, indicating no cognitive impairment, while her PASRR notice of nursing facility approval dated 12/2/15 showed she met the criteria for mental illness as defined by PASRR. Resident #32’s MDS, dated [DATE], also indicated he did not have a state Level II PASRR serious mental illness and/or intellectual disability or related condition. His MDS documented a BIMS score of 12, indicating moderate cognitive impairment. However, his PASRR dated 8/10/17 reflected that he met the criteria for mental illness as defined by PASRR, and an addendum to the PASRR summary of findings dated 12/20/17 documented a Level II approval with specialized services. During interview, the MDS Coordinator confirmed the annual MDS was coded incorrectly for Resident #32 as he was a Level II PASRR resident.
Failure to Provide PASRR-Directed Behavior Management Plan
Penalty
Summary
The facility failed to provide specialized services for Resident #4 as directed by the resident's PASRR. Resident #4's MDS documented a BIMS score of 15, indicating no cognitive impairment, and listed diagnoses of anxiety, depression, bipolar disorder, and schizophrenia. The PASRR dated 12/2/15 directed that the resident required specialized services of a behavior management plan to address anxiety/worry, verbal aggression, abrasiveness/irritable behaviors, and inappropriate communication of anger. However, review of the resident's care plan on 2/17/16 showed that no behavior management plan was in place. During an interview on 2/19/26, the DON stated that there was no behavior management plan for Resident #4, and the Administrator stated in an e-mail that the facility followed the PASRR provider's guidelines for completing PASRRs.
Improper Incontinent Care and Infection Control During Brief Change
Penalty
Summary
Appropriate care for residents who are continent or incontinent of bowel and bladder, appropriate catheter care, and appropriate care to prevent UTIs was not provided when staff failed to follow infection control practices during incontinent care for Resident #7. Resident #7 had a BIMS score of 13, required partial/moderate assistance with lower body dressing and toileting hygiene, was frequently incontinent of bowel and bladder, and had diagnoses including renal failure, diabetes mellitus, and hypertension. Her care plan identified bowel and bladder incontinence related to cognitive impairment and mobility and noted she got frequent UTIs, with peri-care to be focused on twice per day. The care plan did not include direction for enhanced barrier precautions during care. During observation, Staff F and Staff E donned EBP and explained incontinent care would be provided. After Staff F completed the resident’s incontinence care, she used dirty gloves to open a clean brief and place it under the resident. Staff F then removed her dirty gloves and fastened the brief without performing hand hygiene. Staff F later stated she should have removed her gloves and performed hand hygiene before placing the clean brief, and the DON acknowledged observing the improper incontinent care. The resident had recently been treated for a UTI, with a physician note documenting flank pain, later ER transfer, and return to the facility with orders for cefdinir and ondansetron; the final urine culture showed >100,000 CFU/ml E. coli mixed growth.
Failure to Obtain Ordered Daily Weights and Report Weight Gains
Penalty
Summary
The facility failed to obtain daily weights and failed to notify the doctor of 3-pound weight gains in a day as ordered for one resident reviewed for nutrition. The resident had severe cognitive impairment with a BIMS score of 6 and diagnoses including aphasia, metabolic encephalopathy, and acute respiratory failure. The doctor’s order, signed on 11/25/25, directed staff to obtain daily weights and notify the doctor of weight greater than 3 lb. in a day and 5 lb. in a week starting 9/12/25. Review of the resident’s EHR showed 3-pound weight gains from the prior day on 11/24/25, 12/11/25, and 12/25/25, but progress notes did not show notification to the doctor for those gains. The weight record also lacked daily weights on multiple dates, including 11/21/25, 11/29/25, 11/26/25, 1/3/26, 1/8/26, 1/12/26, 1/19/26, 1/27/26, 1/29/26, 2/4/26, 2/7/26, and 2/14/26. The DON stated the resident had significant edema without a cause a few months earlier, which was why daily weights were started, and the Administrator stated staff were expected to obtain the weight daily and enter it into the system for review.
Improper Medication Handling During Pass
Penalty
Summary
The facility failed to ensure infection control prevention and practices to prevent touching medication with bare hands or dirty gloves during medication administration for 3 of 5 residents observed, including Residents #27, #1, and #11. During the medication administration task, Staff B, a CMA, did not perform hand hygiene before beginning the pass, applied gloves, opened the double-lock narcotic drawer, touched the computer mouse with a gloved hand, handled multiple resident medication cards, and retrieved Resident #27’s methadone card before punching the pill into her gloved hand and placing it into a medication cup. Staff B then administered the medication to Resident #27. Staff B also handled Resident #1’s Eliquis, metoprolol, omeprazole, spironolactone, and stock acetaminophen by popping pills directly into her hand and placing them into a medication cup, including shaking acetaminophen into the palm of her left hand. For Resident #11, Staff B again failed to perform hand hygiene, placed her fingers inside a plastic cup, handled multiple drawers and bottles on the medication cart, shook aspirin, multivitamins, and Senokot S into her hand, and prepared Miralax in a plastic cup before administering the medications. Staff C, Staff D, and the DON stated hand hygiene should be performed between residents’ medication passes, and the facility policy directed hand hygiene before and after each resident’s medication pass and stated medications should not be touched.
Failure to Implement Care Plan Chair Alarm Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as being at risk for falls. The resident, who had severe cognitive impairment as indicated by a BIMS score of 2 out of 15, required substantial to maximal assistance for transfers and ambulation. The care plan, created in February and updated in March, included the use of a chair alarm to alert staff when the resident attempted to self-transfer. However, on the date of the incident, staff observed the resident stand up impulsively from a wheelchair and immediately fall. Multiple staff members present during the fall did not recall a chair alarm being in place at the time. Interviews with staff, including the staffing coordinator, activities director, social services designee, and DON, confirmed that the chair alarm, as specified in the care plan, was not in use during the fall. The facility's policy required the use of alarming devices to alert staff of position changes for residents with diminished cognition. Despite this policy and the care plan intervention, the chair alarm was not implemented at the time of the incident, resulting in a failure to follow the established care plan for fall prevention.
Resident Dignity Compromised by Staff's Use of Profanity
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA), referred to as Staff B, who used offensive language in the presence of a resident, identified as Resident #4. Resident #4, who has intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported that Staff B entered her room during the night and began yelling about a Licensed Practical Nurse (LPN), referred to as Staff A, using derogatory language. Resident #4 expressed discomfort with Staff B's behavior, noting that it was inappropriate for Staff B to speak negatively about other staff members in her presence. Staff B admitted to using profanity and acknowledged that it was inappropriate to do so in front of a resident. The Director of Nursing (DON) and other staff members, including a Registered Nurse (RN), confirmed that the use of profanity in front of residents is unacceptable and violates the facility's policy on resident rights, which emphasizes treating residents with dignity and respect. The incident was corroborated by Staff A, who reported previous altercations with Staff B and confirmed that Resident #4 had informed him of the incident. The facility's policy on dignity and respect outlines the expectation for staff to provide considerate and respectful care, which was not upheld in this instance.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) during catheter care for three residents, leading to a deficiency in infection prevention and control. Resident #5, who has moderate cognitive impairment and uses an indwelling catheter due to neurogenic bladder, was observed receiving catheter care without the use of an isolation gown by Staff G, CNA. Despite the care plan indicating the need for EBP, including the use of gowns, no EBP sign was present in or outside the resident's room, and staff were unaware of the requirement. Similarly, Resident #4, with intact cognition and an indwelling catheter for neurogenic bladder, was observed receiving catheter care from Staff D, CNA, without the use of an isolation gown, despite the presence of a CDC sign indicating the need for such precautions. Interviews with staff revealed a misunderstanding of the requirement for gowns, with some staff believing their use was optional. The Director of Nursing (DON) confirmed that all residents with urinary catheters should be on EBP, but acknowledged issues with signage and PPE availability. Resident #10, who has intact cognition and uses an indwelling catheter for benign prostatic hyperplasia and obstructive uropathy, also received catheter care without the use of an isolation gown by Staff E. The DON confirmed the absence of a PPE isolation bin and EBP sign in Resident #10's room. The facility's failure to consistently implement EBP as per CDC guidelines and their own policy resulted in a deficiency in infection prevention and control measures.
Failure to Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days of a resident's hospice election. Resident #23, who was reviewed for hospice care, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive loss and was dependent on staff for activities of daily living. The resident had diagnoses of cancer, end-stage renal disease, diabetes mellitus, and Non-Alzheimer's Dementia. Despite being signed into hospice care by a family representative, the MDS lacked documentation of hospice care services, and the SCSA MDS was not set up within the required timeframe. The MDS Coordinator acknowledged awareness of the resident's hospice admission but admitted that the SCSA MDS was missed. The Director of Nursing (DON) reported that hospice admissions are communicated via slips, which are not retained, and expected the MDS Coordinator to complete the SCSA MDS as per the Resident Assessment Instrument (RAI) guidelines. The RAI manual specifies that the SCSA MDS must be completed within 14 days from the determination of a significant change in resident status, such as enrollment in a hospice program, which was not adhered to in this case.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to provide a full assessment for a resident who was involved in a fall incident. The resident, who had a history of functional impairment in both lower extremities and used a walker, fell and was found by the Assistant Director of Nursing (ADON) exhibiting signs of a left hip injury. Despite the resident's inability to bear weight on the left leg and the presence of pain, the ADON assisted the resident to a standing position without conducting a proper assessment, including vital signs and range of motion (ROM) evaluation. The incident report initially documented by the ADON was later amended, revealing discrepancies in the account of the fall and the actions taken. The ADON admitted to not performing a full assessment before moving the resident and acknowledged altering the documentation. The resident was eventually diagnosed with a left hip fracture and later found to have additional rib fractures. The facility's investigation concluded that the fall was unavoidable, but the lack of proper assessment and documentation by the ADON was evident. Interviews with staff and the Director of Nursing (DON) confirmed that the ADON did not follow the facility's fall care path, which requires a complete assessment before moving a resident after a fall. The DON and Administrator noted the absence of vital signs and ROM assessment in the incident report. The ADON was suspended and later terminated for falsifying documentation. The facility had recently discontinued the use of fall alarms, which was a concern for the resident's family, and staff were instructed to increase monitoring of residents.
Dietary Service Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility, which had a census of 35 residents, was found to be non-compliant during a survey. During an interview, the Dietary Manager mentioned that she was in the process of enrolling in dietary manager classes. Another interview with the Consultant Dietician revealed that the Dietary Manager was not certified but was currently taking the course. The review of the Dietary Manager's employee file confirmed the absence of a certificate of completion for the Dietary Manager courses.
Failure to Follow Physician Orders for Urology Referral
Penalty
Summary
The facility failed to follow physician orders for a resident with intact cognition, as indicated by a BIMS score of 15. The resident had diagnoses of benign prostatic hyperplasia, anxiety, and hypertension. A physician order for a referral to Urology was made on 1/22/24, but the facility's Electronic Health Record and Progress Notes lacked documentation of an appointment being made or a call to schedule the appointment. The Director of Nursing confirmed that no appointment was scheduled and that there was no documentation of any call to Urology. The facility did not have a policy for handling physician orders and claimed to follow professional standards.
Failure to Conduct Proper Assessments for Resident's Range of Motion and Mobility
Penalty
Summary
The facility failed to ensure proper assessments were conducted for a resident to determine if she remained at baseline or had experienced a decline in her range of motion (ROM) and mobility. Resident #15, who had impairments on both sides of her upper and lower extremities, was not included in a restorative care program. Observations revealed that the resident was often left unattended and without a call light, and staff only responded after she had been yelling for help for several minutes. The Director of Nursing (DON) and other staff members acknowledged that the resident had refused restorative care in the past, but there was no documentation of ongoing assessments to confirm her baseline status or need for therapy. The last documented therapy screen was outdated, and the facility did not conduct a new assessment during the resident's annual review as required. Interviews with the DON, MDS Coordinator, Assistant Director of Nursing (ADON), and Occupational Therapist (OT) revealed a lack of clarity and communication regarding the responsibility for conducting ROM assessments and therapy screens. The MDS Coordinator was unaware of the need to check ROM during annual assessments, and the ADON admitted to not performing the required annual therapy screens. The OT confirmed that therapy staff were not informed of residents' annual assessment schedules and relied on weekly Medicare meetings for referrals. The facility's process for ensuring therapy evaluations was not followed, resulting in missed assessments and a failure to document the resident's refusals and baseline status accurately.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riceville Family Care And Therapy Center | 9.5 mi | ★★★★★ | 5 | 0 |
| New Hampton Nursing & Rehab Center | 14.8 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of New Hampton | 14.9 mi | ★★★★★ | 2 | 0 |
| Chautauqua Guest Home #3 | 17.4 mi | ★★★★★ | 0 | 0 |
| Chautauqua Guest Home #2 | 17.6 mi | ★★★★★ | 3 | 0 |
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