Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Ii during CMS and state inspections, most recent first.
A resident with end-stage renal disease receiving thrice-weekly dialysis was not assessed or monitored by nursing staff before or after multiple dialysis sessions, despite a facility policy requiring such monitoring and documentation. The resident, who was cognitively intact, reported that nurses did not examine the dialysis shunt site or perform assessments related to dialysis, and record review showed no documented monitoring on numerous treatment days. An RN acknowledged that assessments were only done if the resident felt unwell or had abnormal BP, while the DON stated that nurses were expected to assess the resident after dialysis and document their findings.
Staff failed to follow the facility’s enhanced barrier precautions policy when two CNAs provided urinary catheter care to a cognitively impaired resident with an indwelling catheter and physician-ordered monthly catheter changes for urinary retention. Although privacy was provided and gloves were used, the CNAs did not wear gowns as required by the resident’s care plan and the facility’s policy, which mandated gloves and gowns for high-contact care and whenever touching the resident or their environment.
A facility failed to submit the results of an abuse investigation to the state within the required five business days. The incident involved a wheelchair-bound resident with a mental disorder who was mistreated by a CNA. The incident was reported to the state, family, and police, and the CNA was terminated. However, the final report was not submitted on time, and the administrator did not retain the fax confirmation, leading to a deficiency in compliance with state regulations.
The facility did not report an allegation of abuse within the required 24-hour period to the OSDH. A CNA witnessed abuse but delayed reporting it to an LPN, resulting in the incident being reported late. This deficiency was identified during a review of records and interviews, affecting one of the three sampled residents reviewed for abuse allegations.
The facility did not provide required training on abuse and neglect prevention and reporting for a CNA during orientation. The DON confirmed the absence of documentation for this training, which is mandated by the facility's policy.
The facility failed to submit the PBJ report for the first quarter of 2024 within the required time frame. The administrator confirmed that the report, based on payroll data, was not submitted as required. The facility's policy is to complete these reports quarterly. At the time of the deficiency, 38 residents resided in the facility.
The facility failed to develop and implement a policy and procedure for monitoring Legionella. The maintenance director could not provide specific measures to prevent Legionella growth, and the administrator and DON confirmed the absence of such a policy.
The facility failed to transmit a resident's assessment within seven days of completion due to a system glitch and oversight by the MDS coordinator. The assessment was eventually submitted after the issue was identified.
The facility failed to update the care plans for two residents who experienced falls, leading to a deficiency in care. One resident with Parkinson's disease had eight un-witnessed falls, and another resident with hemiplegia suffered a head injury from a fall. Despite these incidents, their care plans were not updated with new interventions.
The facility failed to ensure psychotropic medications were necessary for three residents, with improper documentation and lack of appropriate diagnoses for conditions such as dementia and agitation. Despite pharmacist recommendations for dose reductions and proper diagnoses, the medications were continued without sufficient justification.
Failure to Assess and Monitor Dialysis Resident Before and After Treatments
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a dialysis-dependent resident before and after dialysis treatments, contrary to its own dialysis policy. The undated dialysis policy required nursing staff to monitor residents before and after dialysis, protect and observe dialysis access sites for signs of infection or complications, and document all dialysis-related care, observations, and communications in the medical record. The resident’s care plan, initiated for end-stage renal disease with scheduled dialysis on Tuesday, Thursday, and Saturday, included goals to manage the condition and ensure safe transport to and from dialysis. The admission assessment documented that the resident had intact cognition with a BIMS score of 13 and received dialysis services. Record review showed no nursing monitoring documented before or after multiple scheduled dialysis treatments on 12/16/25, 12/18/25, 12/20/25, 12/23/25, 12/26/25, 12/27/25, 12/30/25, 01/02/26, 01/03/26, and 01/06/26. During interviews, the resident reported attending dialysis three times weekly, being transported by a transportation company during the week and by family on weekends, and stated that facility nurses did not look at the dialysis shunt site or assess them before or after dialysis. Observation confirmed the presence of a dialysis shunt on the resident’s left forearm. An RN stated they did not assess the resident before or after dialysis unless the resident felt unwell or had abnormal blood pressure, and that the shunt was assessed only if there was a concern. The DON stated that nurses should assess the resident upon return from dialysis and document findings in the nurse’s notes.
Failure to Use Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when two CNAs provided urinary catheter care to a resident without using required enhanced barrier precautions. Observation showed that the CNAs appropriately provided privacy, set up supplies, and donned gloves, but they did not wear gowns while performing catheter care, despite facility policy and the resident’s care plan requiring both gloves and gowns for such high-contact care. The facility’s undated Enhanced Barrier Precautions policy specified that residents with catheters require enhanced barrier precautions, including the use of gloves and gowns whenever touching the resident or their environment, to prevent the spread of infections, especially multidrug-resistant organisms. The resident’s care plan, initiated for an indwelling catheter and risk for infection and complications, directed staff to consistently use gowns, gloves, and hand hygiene during high-contact care. A recent quarterly assessment documented that the resident had severely impaired cognition, with a BIMS score of 03, and an indwelling urinary catheter, and a physician’s order required monthly catheter changes for urinary retention. During interviews, both CNAs and the ADON acknowledged that gowns should have been worn during the catheter care under enhanced barrier precautions.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to submit the results of an abuse investigation to the state within the required five business days for a resident who was reviewed for abuse. The incident involved a resident with a mental disorder who was wheelchair-bound. The incident occurred when a CNA aggressively spun the resident's wheelchair, yelled in their face, and pushed them away from a table. The incident was initially reported to the state, and the resident's family, legal representative, and police were notified. Cameras were in use at the time, and the CNA involved was sent home and reported to the nurse aide registry. The final report of the incident was not submitted to the state within the required timeframe. The administrator acknowledged that the final report, which was labeled as both initial and final, was not faxed within five days, and they did not retain the fax confirmation. The facility's policy required reporting within two hours if there was bodily injury, but this incident was reported within 24 hours. The failure to submit the final report in a timely manner constituted a deficiency in the facility's compliance with state regulations.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 24-hour timeframe to the Oklahoma State Department of Health (OSDH). The incident involved a certified nursing assistant (CNA) who reported witnessing abuse on June 1, 2024, but did not inform the licensed practical nurse (LPN) until June 2, 2024. The incident report was subsequently faxed to the authorities on June 3, 2024, at 2:57 p.m., exceeding the 24-hour reporting requirement. This deficiency was identified during a review of records and interviews, highlighting a lapse in the facility's protocol for timely reporting of abuse allegations. The facility had 38 residents at the time of the incident, and the deficiency was noted for one of the three sampled residents reviewed for allegations of abuse.
Failure to Provide Abuse/Neglect Training for CNA
Penalty
Summary
The facility failed to ensure that training was provided for activities that contribute to abuse and neglect, procedures for reporting incidents of abuse and neglect, and abuse prevention. This deficiency was identified during a review of records and interviews, specifically concerning one certified nursing assistant (CNA) who did not receive the required training during their orientation. The facility's policy and procedure for training nurses and CNAs, which includes documentation of training dates, completion status, competency assessment results, and certificates of participation or completion, was not followed. The Director of Nursing (DON) confirmed that there was no documentation of the CNA having completed abuse/neglect training, including reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property during their orientation.
Failure to Submit PBJ Report for Q1 2024
Penalty
Summary
The facility failed to submit the Payroll-Based Journal (PBJ) report for the first quarter of 2024 within the required time frame. The administrator confirmed that the PBJ report, which is based on payroll and other verifiable and auditable data, was not submitted as required. The facility's policy is to complete these reports quarterly. At the time of the deficiency, 38 residents resided in the facility.
Failure to Implement Legionella Monitoring Policy
Penalty
Summary
The facility failed to develop and implement a policy and procedure for monitoring Legionella. During a survey, the maintenance director was unable to provide a specific policy for measures to prevent the growth of Legionella, including descriptions of the water systems for visible inspection and steps to prevent the growth of Legionella in a flow diagram. The ADON/IP reported that there had not been any cases of Legionella. When asked, the administrator and DON confirmed that they did not have a policy and procedure related to Legionella.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to ensure the resident assessment was transmitted within seven days of completion for one resident reviewed for discharge assessments. The Director of Nursing (DON) reported that there was a glitch in the system, and the MDS coordinator did not receive a report indicating that the resident's MDS had not been submitted. The MDS assessment was eventually submitted the day before the review. The MDS coordinator confirmed over the phone that there was a software issue with PCC and that they did not notice whether the report was accepted or rejected. The MDS was modified due to re-entry dates and was signed and transmitted the previous day.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update the care plans for two residents who experienced falls, leading to a deficiency in care. Resident #22, who has Parkinson's disease and is at high risk for falls, had eight un-witnessed falls documented between January and May 2024. Although immediate actions were taken after each fall, the care plan was not updated with new interventions to prevent future falls. The Director of Nursing (DON) acknowledged that the care plan had not been updated and indicated that RN #1 was responsible for this task but had not completed it. Resident #29, diagnosed with hemiplegia and severe cognitive impairment, experienced a fall in March 2024 that resulted in a head injury and hematomas. Despite the incident and subsequent emergency room visit, the care plan was not updated with new fall interventions. The Assistant Director of Nursing (ADON) confirmed that care plans should be updated with new interventions after each fall but admitted that not all care plans had been updated accordingly.
Failure to Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary to treat specific conditions indicated in the clinical records for three residents. Resident #7 was prescribed multiple medications, including Ativan, Buspirone, Klonopin, Zoloft, and Zyprexa, for conditions such as agitation and dementia without proper documentation of behaviors justifying their use. The Assistant Director of Nursing (ADON) acknowledged that the pharmacist had requested appropriate diagnoses and that the residents were under the care of a geriatric psychiatric facility, but the necessary changes were not made in the records. Behavioral charting for Resident #7 was inconsistent, with only partial documentation for March, April, and May 2024. Additionally, the Buspirone order was incorrectly documented for dementia instead of anxiety, which the ADON admitted needed correction. Resident #14, diagnosed with dementia, was prescribed Risperidone without documented psychotic behaviors to justify its use. A pharmacist's review noted no psychotic behaviors, yet the medication was continued. Similarly, Resident #31, also diagnosed with dementia, was prescribed Risperidone without appropriate diagnoses or behaviors documented to justify its use. Despite a pharmacist's recommendation for a gradual dose reduction, the physician disagreed, citing controlled agitation as the reason for maintaining the current dosage. The ADON reported that the physician preferred using Risperidone to control behaviors in residents with dementia, despite the lack of documented justification.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hollis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellington Care Center | 20.4 mi | ★★★★★ | 8 | 0 |
| Avir At Childress | 24.1 mi | ★★★★★ | 3 | 0 |
| Mangum Skilled Nursing And Therapy | 27.5 mi | ★★★★★ | 0 | 0 |
| Magnolia Creek Skilled Nursing And Therapy | 34.1 mi | ★★★★★ | 1 | 0 |
| English Village Skilled Nursing And Therapy | 34.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Colonial Manor Ii.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.