Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Nursing & Rehabilitation Home during CMS and state inspections, most recent first.
CNA Failed to Wear Required PPE for Resident on EBP: A CNA provided personal care to a resident with a PEG tube, wounds, and severe cognitive impairment while wearing gloves but not a gown, despite the resident being on EBP and the care plan requiring gowns and gloves for all personal care. The CNA later confirmed the lapse, and the CNA supervisor confirmed the gown should have been worn.
Surveyors found that kitchen equipment was not maintained in safe and clean condition, including a refrigerator with three torn door seals, a broken toaster, another toaster missing a crumb catcher, and two toasters stored full of bread crumbs. Multiple full-size and half pans were covered in a black hardened substance, two ovens were coated with hardened black residue with one containing several silver pieces of material, and a microwave had dark splattered material on its top and sides. The dietary manager and the administrator both acknowledged that kitchen equipment should be in good repair and clean.
Kitchen staff were observed working without proper hair restraints, including a cook without a hairnet and later without a beard covering, and the facility did not have beard coverings available. Surveyors also found multiple opened food items in dry storage without open dates, milk containers in the walk-in cooler with outdated dates, and unlabeled items in the freezer. The Dietary Manager and Administrator confirmed the items and staff practices did not follow facility policy.
Improper garbage and refuse disposal was observed in the kitchen, dining area, and outside dumpster area. Surveyors found a kitchen trash can without a foot pedal, an uncovered trash can in the dining area, and a dumpster with rusted cracks and a metal separation that exposed trash inside. The Dietary Mgr confirmed the uncovered and improperly equipped trash containers, and the Administrator confirmed trash should be contained appropriately.
A resident with multiple comorbidities, moderate cognitive impairment, and dependence on staff for ADLs was found to have a large bruise on the right shoulder/armpit area, with no clear cause identified and while receiving Eliquis. Nursing staff documented the bruise, noted the recent use of a sling lift and the resident’s history of easy bruising, and verbally educated CNAs on positioning techniques. The DON and Administrator were aware of the injury and treated it as an injury of unknown origin, but they did not report it to the State Agency within the required 24-hour timeframe, contrary to the facility’s incident/accident and abuse reporting policies.
A resident with multiple comorbidities, moderate cognitive impairment, total dependence for transfers, and on Eliquis was observed with a large bruise on the right shoulder/armpit and could not state how it occurred. Documentation showed the bruise had been present for some time, was first reported by a hospice CNA, and measured 7 cm by 3 cm. Staff referenced recent use of a sling lift and noted the resident bruised easily, but the DON and Administrator acknowledged that no full investigation or incident report was completed for this injury of unknown origin, contrary to facility policies requiring investigation and documentation of such incidents and potential abuse indicators.
Environmental Maintenance Deficiencies: Two residents were affected by environmental upkeep issues. One resident’s AC/heat vent had a black substance on it, and another resident’s bathroom sink faucet was corroded and cracked with a gap under the cold water tap; the Administrator confirmed both conditions during observation.
Infection control failures were identified during catheter care, wound care, PEG care, and transmission-based precautions. A CNA did not wear a gown while providing catheter care to a resident on EBP, a treatment nurse did not follow infection control steps during wound care, an LPN left piston syringes assembled and unrinsed after bolus feeding, and a resident’s door lacked TBP signage despite the resident having multiple pressure and venous ulcers.
A resident with hemiplegia, diabetes, hypertension, late syphilis, and unspecified dementia with behavioral symptoms had a PRN order for Oxazepam 15 mg at night for insomnia written without a discontinue date. Pharmacy consultant review noted that PRN psychotropic medications must be limited to 14 days, with prescriber evaluation, documented rationale, and a specific duration if extended. The physician did not specify a duration for this PRN psychotropic order, and the DON confirmed the absence of a defined time limit, resulting in noncompliance with requirements to prevent unnecessary psychotropic use and chemical restraint.
Care Plan Not Updated After New Bruise Identified: A resident with dementia, AFib, CHF, RA, and a history of right breast cancer was found with a large bruise under the right shoulder/armpit area while receiving Eliquis. The bruise was documented by nursing, but the care plan was not updated to reflect the new finding even though the plan already addressed anticoagulant therapy and skin monitoring.
A resident with a history of falls and other medical conditions fell in the facility, but the physician and family were not notified as required by the facility's fall prevention program. Staff confirmed the resident was assessed and found to have no injuries, but the necessary notifications were not made, as verified by the facility's administrator and DON.
A resident with a history of falls and cognitive impairment was found on the floor by staff, but the LPN did not document a post-fall assessment or complete an incident report as required by the facility's fall prevention policy. Despite the resident showing no immediate signs of injury or pain, the necessary documentation and reporting were not conducted, leading to a deficiency in care.
A resident with cognitive impairments was found with socks on her hands to prevent self-scratching, which she could not remove herself, classifying them as restraints. The facility lacked documentation of a pre-restraint assessment, consent, and monitoring, violating their restraint-free policy.
A facility failed to implement a comprehensive care plan for a resident on anticoagulants. The resident, who was taking Eliquis, was observed with bruising on her hands, which was not documented by nursing staff as required. The care plan included monitoring for bruising, but the MAR entries incorrectly indicated no bruising. The ADON confirmed the oversight.
The facility failed to ensure water temperatures in resident rooms were below 120 degrees, with temperatures ranging from 127.0 to 127.8 degrees confirmed by the Maintenance Supervisor and Assistant Administrator.
A resident with a history of pressure ulcers and at moderate risk was observed multiple times without prescribed heel protectors, despite having a physician's order for them to be worn at all times. Interviews with staff revealed a lack of adherence to the care plan, with an LPN unsure of the resident's compliance and a CNA admitting to not placing the protectors on the resident.
A facility failed to implement its infection control policy for enhanced barrier precautions for a resident with a Foley catheter. There was no signage on the resident's door, and no PPE supplies were available nearby, despite the policy requiring these measures. The Assistant DON confirmed the oversight.
A resident in a long-term care facility, who was cognitively impaired and had multiple medical conditions, was verbally and physically abused by a CNA. The abuse was captured on video, showing the CNA using derogatory language and physically mishandling the resident, causing distress and harm. The incident was reported by the resident's family member, and the facility confirmed the abuse, acknowledging the severe psychosocial harm caused to the resident.
A resident with severe cognitive impairment and mobility issues was denied assistance to the restroom by a CNA, who instructed the resident to use their brief instead. This incident was confirmed by video footage and acknowledged by the facility's administrator as inappropriate.
A resident with severe cognitive impairment was verbally and physically abused by a CNA, as captured on video by the resident's family. The facility's Administrator failed to report the incident to the State Survey Agency within the required timeframe, submitting the report more than 24 hours after being informed of the abuse, which violated state regulations.
CNA Failed to Wear Required PPE for Resident on EBP
Penalty
Summary
The facility failed to ensure CNAs had the specific competencies and skill sets necessary to care for a resident on Enhanced Barrier Precautions (EBP) by not wearing the required PPE during care. The deficiency was identified during observation, record review, and interviews involving a resident with a gastrostomy tube, muscle wasting and atrophy, vascular dementia, hemiplegia and hemiparesis, severe cognitive impairment, pressure ulcers, and a feeding tube. The resident’s care plan indicated EBP related to PEG placement and wounds to the left heel and right lateral buttock, and direct care staff were to use gowns and gloves for all personal care. During observation, a CNA was seen providing a bed bath to the resident while wearing gloves but not a gown. The CNA later confirmed the resident was on EBP and that she did not wear a gown when providing care. The CNA supervisor confirmed the resident was on EBP and that the CNA should have worn a gown during care. The administrator and DON were notified of the CNA not wearing the appropriate PPE while providing care to the resident on EBP.
Failure to Maintain Kitchen Equipment in Safe and Clean Condition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain kitchen equipment in safe operating condition and in a clean state. During an initial kitchen tour, they observed three torn door seals on three individual refrigerator doors on one refrigerator, one broken toaster, and another toaster missing a crumb catcher. Two of the three toasters were stored while full of bread crumbs. In addition, four full-size pans and four half pans were covered in a black hardened substance, two ovens were covered with a hardened black substance, one oven contained four silver pieces of material approximately the size of a golf ball, and a microwave had a dark splattered substance on its top and sides. In interviews, the Dietary Manager confirmed that kitchen equipment should be working and clean, and the Administrator confirmed that the equipment in the kitchen should be in good repair and clean.
Kitchen Food Safety and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to ensure proper hair restraint for kitchen staff and failed to store food and discard expired items in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed S6Cook working in the kitchen without a hairnet or other hair covering, and later observed the same cook without a beard covering. The cook confirmed forgetting the hair covering, and then explained that the facility did not have any beard coverings available. The Dietary Manager later confirmed that the cook should have been wearing a beard net and that the facility did not have any available. The Administrator also confirmed that staff should wear hair nets and beard coverings according to facility policy. Surveyors also found multiple food storage and date-marking issues in the dry storage area, walk-in refrigerator, and walk-in freezer. In dry storage, several opened items were not labeled with open dates, including cake mix, gingerbread mix, cornmeal, brownie mix, peach drink mix, cheese sauce powder mix, and mouse mix. In the walk-in refrigerator, individual containers of whole milk were dated December 23 and December 28, and reduced fat milk was dated January 4. In the walk-in freezer, surveyors found loaves of bread, a bag of sausage pieces, and a bag of cookies with no identifying information or dates. The Dietary Manager confirmed the opened items should have been labeled with open dates and that the milk containers dated December 23 and December 28 should not have remained in the walk-in cooler. The Administrator confirmed that kitchen items should be labeled and dated with open dates and that staff should follow facility policies.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not disposed of properly. During the initial kitchen tour, surveyors observed only one trash can in the kitchen, and it was covered but did not have a foot pedal. They also observed an uncovered trash can in the dining area attached to the kitchen and separated from the dishwashing area by an open window. On a later observation of the outside dumpsters, one dumpster had three large, long rusted horizontal cracks on the bottom front that made items inside visible, and the same dumpster had a corner with a large separation in the metal that exposed a white trash bag and other items inside. The facility policy stated that garbage and refuse containers should be covered when not in use and that outside dumpsters should have tightly fitting lids, doors, or covers and be kept covered when not being loaded. The Dietary Manager confirmed the kitchen trash can did not have a foot pedal and the trash can in the kitchen/dining area was uncovered, and the Administrator confirmed all trash should be discarded and contained appropriately.
Failure to Report Injury of Unknown Origin Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency within the required 24-hour timeframe. Facility policies on incidents/accidents and on abuse, neglect, and exploitation require that injuries of unknown origin be treated as reportable events, with written procedures for identifying, investigating, and reporting such occurrences. The abuse policy specifies that all alleged violations, including injuries of unknown origin, must be reported to the Administrator and appropriate state agencies within specified timeframes, including not later than 24 hours if the events do not involve abuse or serious bodily injury. Resident #55, who had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast, was identified as having a large bruise on the right shoulder/armpit area. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented dependence on staff for all ADLs, including substantial/maximal assistance with rolling in bed and dependence for transfers. On observation, the resident was unable to state how the bruise occurred, and a CNA reported that the bruise had been present for several weeks without a known cause. The resident was also receiving Eliquis 2.5 mg twice daily. Nursing documentation dated 12/04/2025 showed that the treatment nurse was notified by a hospice CNA of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and could not recall how the bruise was acquired, and the treatment nurse noted that a sling lift had been used earlier in the week and that CNAs were verbally educated on proper lift techniques and positioning. The DON later documented that the lift used did not go under the arms and that the resident had a history of easy bruising and skin tears, and acknowledged that CNAs sometimes assisted the resident by placing a hand under her arm for repositioning. During interviews, the LPN and DON confirmed awareness of the bruise and that it had been reported internally to the DON and Administrator, but the DON and Administrator both confirmed that the injury of unknown origin was not reported to the State Agency as required by facility policy and state law.
Failure to Investigate Injury of Unknown Origin to Resident’s Shoulder/Armpit
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin in accordance with its own incident/accident and abuse policies. The facility’s policies required staff to report, investigate, and document incidents and accidents, including injuries of unknown origin, and to conduct an immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation. These policies also required identification and interviewing of all involved persons and complete documentation of the investigation. Despite these written requirements, the facility did not complete a full investigation when a large bruise of unknown origin was identified on a resident’s right shoulder/armpit area. The resident involved had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast. A quarterly MDS showed moderate cognitive impairment (BIMS score of 8), dependence on staff for all ADLs, substantial/maximal assistance needed for rolling in bed, and total dependence for transfers. The resident was also receiving Eliquis 2.5 mg twice daily. During surveyor observation, the resident was seen sitting up in bed with a large bruise on the right shoulder/armpit and was unable to state how the bruise occurred. Record review showed that on a prior date, a hospice CNA had notified the treatment nurse of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and did not recall how the bruise was acquired. Staff notes referenced use of a sling lift earlier in the week and staff education on proper lift and positioning techniques, and the DON documented that the lift used did not go under the arms and that the resident was an easy bruiser. However, the DON later acknowledged being unsure whether an incident report and investigation were completed, and both the DON and the Administrator confirmed that a full investigation into this injury of unknown origin was not conducted, despite the facility’s policies requiring such an investigation.
Environmental Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents reviewed for environmental concerns. Resident #39’s air conditioning/heating unit had a black substance observed on the vent on 01/05/2026 and again on 01/06/2026, and during an observation with the Administrator on 01/06/2026, the vent was confirmed to have a black substance present and needed to be cleaned. Resident #46’s bathroom sink faucet was observed on 01/05/2026 and 01/06/2026 to be corroded and cracked, with a gap underneath the cold water tap, and during an observation with the Administrator on 01/06/2026, the faucet was confirmed to be damaged and cracked from corrosion and needed to be replaced.
Infection Control Failures During Catheter Care, Wound Care, PEG Care, and Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 4 residents reviewed for infection control. The report identified failures involving enhanced barrier precautions during catheter care for a resident with diagnoses including resistant multiple antibiotics, urinary tract infection, and urinary retention with Foley catheter placement; improper infection control practices during wound care for a resident with a stage 3 pressure ulcer to the left medial distal 1st digit and multiple chronic conditions including diabetes and peripheral venous insufficiency; improper storage of syringes after PEG care for a resident with dysphagia; and the absence of enhanced barrier precaution signage on a resident’s door who had 3 pressure ulcers and 3 venous ulcers and diagnoses including venous insufficiency and type 2 diabetes. For Resident #5, the record showed orders for Foley catheter cleansing and enhanced barrier precautions every shift, with care plan directions for staff to use gowns and gloves for all personal care. During observation of catheter care, the CNA did not wear a gown while providing care, and the CNA confirmed the resident was on enhanced barrier precautions and that a gown should have been worn. For Resident #7, wound care was observed and the treatment nurse did not sanitize the over-bed table before placing supplies on it, did not place a protective barrier between a biohazard bag and the table, did not sanitize the pen light after it contacted the wound, and did not sanitize the over-bed table after removing the biohazard bag. The treatment nurse confirmed these infection control steps were not followed. For Resident #20, after a bolus feeding was completed, the LPN left piston syringes assembled and did not rinse them with warm water; water remained in one syringe tip and tube feeding liquid remained in the other syringe tip. The DON confirmed the syringes should have been disassembled, rinsed, and allowed to dry. For Resident #17, the record showed multiple pressure and venous ulcers, and observation of the room door showed no signage indicating transmission-based precautions. The DON confirmed the proper signage should have been placed on the door.
Failure to Time-Limit PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints and to limit PRN psychotropic medications to 14 days as required. Record review for Resident #2, who was re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, late syphilis, and unspecified dementia with behavioral symptoms, showed a physician’s order dated 10/03/2024 for Oxazepam 15 mg PO PRN every 24 hours at night for insomnia without a discontinue date. The Pharmaceutical Consultant Report dated 10/13/2025 documented that PRN psychotropic medications must be limited to 14 days, with the prescriber required to evaluate the resident before extending the order, document the rationale for any extension, and indicate a specific duration. The report further showed that the physician did not indicate a specific duration for this PRN Oxazepam order, and during interview the DON confirmed that the physician had not specified a duration for the psychotropic PRN order. This failure to include a time-limited duration and required evaluation for the PRN psychotropic medication order for Resident #2 resulted in noncompliance with requirements intended to prevent unnecessary psychotropic use and chemical restraint.
Care Plan Not Updated After New Bruise Identified
Penalty
Summary
The facility failed to update the care plan for a resident after a new bruise was identified on the right shoulder/armpit area. On 01/05/2026, the resident was observed sitting up in bed with a large bruise to that area and was unable to state how it occurred. The resident had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast. The quarterly MDS showed a BIMS of 8, indicating moderate cognitive impairment, and the resident was dependent on staff for all ADLs and required substantial to maximum assistance with rolling in bed. Record review showed the resident was receiving Eliquis 2.5 mg twice daily and had a nursing note from 12/04/2025 documenting that a hospice CNA reported a new large bruise under the right armpit. The treatment nurse assessed the area and documented the bruise as 7 cm by 3 cm with a light purple tint. The care plan already addressed anticoagulant therapy and included daily skin inspections and monitoring for adverse reactions such as bruising, but on 01/07/2026 the current plan of care had not been updated to reflect the bruise when it was identified. The DON agreed the plan of care was not updated when the bruise appeared.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to notify the physician and family after a resident's fall, as required by their fall prevention program. The program mandates that when a resident experiences a fall, the facility must assess the resident, complete an incident report, notify the physician and family, and document all assessments and actions. However, after a resident fell on 02/16/2025, the facility did not fulfill these requirements. Interviews with staff, including CNAs and an LPN, confirmed that although the resident was assessed and found to have no injuries or complaints of pain, the physician and family were not notified of the incident. The resident involved had a medical history that included depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. Despite the resident's fall, there was no documented evidence in the medical record of any notifications made to the family or physician. The facility's administrator and director of nursing confirmed that the LPN should have contacted the physician and family regarding the fall, indicating a lapse in following the established protocol for fall incidents.
Failure to Document Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as outlined in their fall prevention program policy. Specifically, the nursing staff did not document a post-fall assessment or complete an incident report for a resident who experienced a fall. The facility's policy requires that when a resident falls, an assessment must be conducted, an incident report completed, and the physician and family notified. However, these steps were not followed for the resident in question. The resident involved had a history of depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. On the evening of the incident, the resident was found on the floor by staff, but the LPN who assessed the resident did not document any injuries or pain and failed to complete the necessary incident report or post-fall assessment. Subsequent interviews with staff confirmed these omissions, and the facility's investigation revealed that the required documentation and reporting were not completed as per the facility's policy.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. The resident, who was admitted with diagnoses including cognitive communication deficit, Alzheimer's disease, and generalized anxiety disorder, was observed with socks on her hands. This was done to prevent her from scratching herself, as she was at high risk for skin tears. However, the resident was unable to remove the socks on her own, which classifies them as a physical restraint. The facility's policy mandates that restraints should only be used when medically necessary and with proper documentation, including a pre-restraint assessment and consent. In this case, there was no documented evidence of a pre-restraint assessment, restraint consent, or monitoring for the use of the socks as restraints. Interviews with facility staff confirmed the use of socks as restraints and the lack of necessary documentation and monitoring, indicating a failure to adhere to the facility's restraint-free environment policy.
Failure to Document Bruising in Anticoagulant Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who was on anticoagulant medication. During an observation, the resident was found to have bruising on the back of both hands, which she attributed to taking a blood thinner. The medical record confirmed that the resident was prescribed Eliquis, a blood-thinning medication, at a dosage of 2.5 mg twice daily. The care plan included an intervention to monitor for bruising, and the Medication Administration Record (MAR) required nursing staff to check for bruising each shift. However, the December MAR entries consistently indicated that the resident had no bruising, despite the observed bruising. An interview with the Assistant Director of Nursing confirmed the presence of bruising and the failure of the nursing staff to document it on the MAR.
Excessive Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that the water temperature in resident rooms was below 120 degrees, as required. During an inspection on December 16, 2024, the water temperatures in the rooms of four residents were found to be excessively high, ranging from 127.0 to 127.8 degrees. This was confirmed by the S2Maintenance Supervisor, who acknowledged that the temperatures exceeded the safe limit. The S1Assistant Administrator also confirmed that the water temperatures should not exceed 120 degrees, indicating a lapse in maintaining the required safety standards for resident rooms.
Failure to Provide Ordered Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. The resident, who had a history of a stage 3 pressure ulcer on the left heel and was at moderate risk for pressure ulcers, was observed multiple times without the prescribed heel protectors. Despite having a physician's order for heel protectors to be worn at all times, the resident was seen without them on several occasions, both in the Geri chair and in bed, even after being placed on isolation due to a positive COVID test. Interviews with facility staff revealed a lack of adherence to the care plan. The LPN confirmed the resident's high risk for pressure ulcers and the order for heel protectors, but was unsure if they were being used. A CNA admitted to not placing the heel protectors on the resident, and the Assistant Director of Nursing confirmed that the resident should have had them on as ordered. This indicates a breakdown in communication and responsibility among staff regarding the implementation of the resident's care plan to prevent pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program to prevent the transmission of communicable diseases and infections by not implementing its policy for enhanced barrier precautions for a resident with a Foley catheter. During an observation, it was noted that there was no signage regarding Enhanced Barrier Precautions on the resident's door, and no personal protective equipment (PPE) supplies were located nearby. The facility's policy, dated 11/01/2024, specified that catheters were a qualifying condition for enhanced barrier precautions, requiring clear signage and the availability of gowns and gloves outside the resident's room. An interview with the Assistant Director of Nursing confirmed the facility's failure to implement the policy by not placing the necessary signage and PPE near the resident's room.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively impaired and had multiple medical conditions, including dementia, anxiety, and chronic heart failure. The abuse occurred when the CNA was observed on video surveillance being verbally and physically abusive while providing care to the resident. The resident's family member reviewed the footage and reported the incident to the facility administrators. The video footage revealed that the CNA used derogatory language and physically mishandled the resident. The CNA was seen pushing the resident's wheelchair and making threatening remarks. The resident, who was unable to walk and used a wheelchair, was verbally abused and physically forced into bed, resulting in the resident hitting her head against the wall. The CNA's actions were observed to cause distress to the resident, who responded with upset language. The facility's investigation confirmed the abuse, and the administrators acknowledged that a reasonable person would have been very upset by the treatment the resident received. The incident was reported to have caused severe psychosocial harm to the resident, including feelings of dehumanization and humiliation. The facility's policies on abuse, neglect, and exploitation were reviewed, and it was determined that the CNA's actions violated these policies.
Failure to Assist Resident with Restroom Needs
Penalty
Summary
The facility failed to uphold the resident's right to dignity and self-determination by not assisting a resident with severe cognitive impairment to the restroom upon request. The resident, who was admitted with multiple diagnoses including dementia, chronic heart failure, and mobility issues, required limited physical assistance for daily activities such as bed mobility, transfers, eating, and toilet use. Despite these needs, a Certified Nursing Assistant (CNA) refused to assist the resident to the bathroom, instructing them to use their brief instead. This incident was corroborated by video footage reviewed by the resident's family member and the surveyor, which showed the CNA telling the resident to use their brief or hold it. The facility's administrator confirmed that the CNA's actions were inappropriate and that the resident should have been assisted to the restroom as requested.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal and physical abuse involving a resident to the State Survey Agency within the required timeframe. The incident was reported to the Administrator by the resident's family member, who provided video evidence of the abuse. The video footage showed a Certified Nursing Assistant (CNA) making rude comments and handling the resident roughly during care. Despite being informed of the incident, the Administrator did not report it to the State Survey Agency within the mandated two-hour window. The resident involved in the incident was admitted with multiple diagnoses, including severe cognitive impairment, dementia, and other physical and mental health conditions. The resident required assistance with daily activities and was using a manual wheelchair for mobility. The video evidence captured the CNA verbally abusing the resident and physically forcing the resident into bed, resulting in the resident hitting their head against a wall. The Administrator confirmed the abuse occurred but delayed reporting the incident to the State Survey Agency. The report was submitted more than 24 hours after the incident was discovered, violating the facility's policy and state regulations that require immediate reporting of abuse allegations. This delay in reporting represents a significant deficiency in the facility's adherence to abuse reporting protocols.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Rayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rayville Nursing And Rehabilitation | 3.3 mi | ★★★★★ | 9 | 0 |
| Deerfield Nursing And Rehabilitation Center | 15.6 mi | ★★★★★ | 4 | 1 |
| Ouachita Healthcare And Rehabilitation Center | 15.7 mi | ★★★★★ | 5 | 0 |
| Delta Grande Skilled Nursing And Rehabilitation | 18.7 mi | ★★★★★ | 5 | 0 |
| Mary Goss Nursing Home | 18.9 mi | ★★★★★ | 12 | 0 |
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