Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
194% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100 residents
Based on a December 2023 inspection.
Census over time
Inspection Report
Deficiencies: 1
Sep 4, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with resident rights, specifically focusing on promoting and facilitating resident self-determination and choice.
Findings
The facility failed to ensure that Resident #1's brief was changed when soiled, as staff insisted she use the commode instead of changing her brief, potentially denying the resident the opportunity to exercise autonomy and impacting quality of life. The report details extensive review of Resident #1's medical and care records, interviews with staff and the resident, and notes conflicting views on the resident's continence and toileting care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident #1's brief was changed when soiled and insisted she use the commode instead, risking denial of resident autonomy and decreased quality of life. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for self-determination: 4
BIMS score: 15
Care plan goal date: Nov 19, 2025
Care plan date: Jul 2, 2021
Care plan date: Aug 3, 2021
Care plan conference date: Jul 14, 2025
Facility in-service date: Jul 16, 2025
Facility in-service date: Aug 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings related to Resident #1's toileting and continence care |
| LVN B | Licensed Vocational Nurse | Named in findings related to Resident #1's toileting and continence care |
| CNA C | Certified Nursing Assistant | Named in findings related to Resident #1's toileting and continence care |
| CNA D | Certified Nursing Assistant | Named in findings related to Resident #1's toileting and continence care |
| COTA E | Certified Occupational Therapy Assistant | Named in findings related to Resident #1's therapy and toileting ability |
| OT F | Occupational Therapist | Named in findings related to Resident #1's therapy and toileting ability |
| MD | Medical Doctor | Named in findings related to Resident #1's medical assessment and continence |
| SW | Social Worker | Named in findings related to Resident #1's care plan and resident interactions |
| DON | Director of Nursing | Named in findings related to Resident #1's care plan and toileting policies |
| ADM | Administrator | Named in findings related to Resident #1's care plan and facility policies |
Inspection Report
Routine
Deficiencies: 3
Feb 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically to assess compliance with infection control practices and prevent the development and transmission of communicable diseases and infections.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, with observed failures including improper sanitization of blood pressure cuffs between residents, failure of staff to wash or sanitize hands during incontinent care and wound care, placing residents at risk of cross contamination and infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| MA C failed to properly sanitize the blood pressure cuff when moving from one resident to another during medication administration and blood pressure measurement. | Level of Harm - Minimal harm or potential for actual harm |
| CNA A failed to wash or sanitize hands when moving from a dirty to clean surface while performing incontinent care. | Level of Harm - Minimal harm or potential for actual harm |
| LVN B failed to wash or sanitize hands after removing a soiled dressing while performing wound care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA C | Failed to sanitize blood pressure cuff between residents | |
| CNA A | Failed to wash or sanitize hands during incontinent care | |
| LVN B | Failed to wash or sanitize hands after wound care | |
| DON | Director of Nursing | Provided infection control training and stated expectations for hand hygiene and equipment sanitization |
Inspection Report
Routine
Deficiencies: 3
Feb 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically to assess compliance with infection control practices and prevention of communicable diseases and infections among residents.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff failing to properly sanitize equipment and wash or sanitize hands during resident care activities, placing residents at risk of cross contamination and infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| MA C failed to properly sanitize the blood pressure cuff when moving from one resident to another during medication administration and blood pressure measurement. | Level of Harm - Minimal harm or potential for actual harm |
| CNA A failed to wash or sanitize her hands when moving from a dirty to clean surface while performing incontinent care. | Level of Harm - Minimal harm or potential for actual harm |
| LVN B failed to wash or sanitize his hands after removing a soiled dressing while performing wound care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for infection control: 6
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA C | Failed to properly sanitize blood pressure cuff between residents. | |
| CNA A | Failed to wash or sanitize hands when moving from dirty to clean surface during incontinent care. | |
| LVN B | Failed to wash or sanitize hands after removing soiled dressing during wound care. | |
| DON | Director of Nursing | Provided infection control training and stated expectations for hand hygiene and equipment sanitation. |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Dec 23, 2023
Visit Reason
The inspection was conducted due to complaints and investigations related to resident-on-resident sexual abuse incidents involving multiple residents at Colonial Manor Nursing Center.
Findings
The facility failed to protect residents from sexual abuse involving three residents (RES #40, RES #18, and RES #27). Multiple incidents of inappropriate sexual contact occurred without appropriate care plan updates or interventions. An Immediate Jeopardy was identified but later removed. The facility lacked adequate interventions and documentation to prevent further abuse.
Complaint Details
The complaint investigation revealed incidents on 9/7/2023, 11/20/2023, and 9/29/2023 involving residents RES #28, RES #18, RES #27, and RES #40. The facility failed to update care plans or implement adequate interventions following these incidents. An Immediate Jeopardy was identified on 12/22/2023 and removed on 12/23/2023. Police were involved, and residents were assessed for trauma with no physical injuries found. The facility's response and documentation were inadequate.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse including inappropriate touching and kissing among residents. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Census: 100
Staff training attendance: 30
Staff training attendance: 41
Staff training attendance: 64
Medication dosage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Witnessed and reported sexual abuse incident on 9/7/2023 |
| LVN D | Licensed Vocational Nurse | Responded to sexual abuse incident on 9/7/2023 and separated residents |
| ADON | Assistant Director of Nursing | Responded to incident on 9/7/2023, performed skin assessment, called police |
| DON | Director of Nursing | Interviewed regarding care plan updates and interventions for sexual behaviors |
| ADM | Administrator | Interviewed regarding incident reporting and care plan confidentiality |
| SS | Social Services | Interviewed regarding resident cognitive ability and care plan updates |
| LPN A | Licensed Practical Nurse | Interviewed about sexual contact policies on secure unit |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 6
Nov 27, 2023
Visit Reason
The investigation was conducted due to complaints and incidents involving resident abuse, specifically sexual abuse and failure to accommodate residents' needs, including call light accessibility and respiratory care.
Findings
The facility failed to ensure residents had access to call lights, failed to prevent sexual abuse incidents involving multiple residents, failed to update care plans after abuse incidents, failed to develop baseline care plans timely, failed to provide appropriate respiratory care, and failed to store food safely with proper labeling and sealing.
Complaint Details
The complaint investigation was triggered by multiple incidents of resident abuse, including sexual abuse involving residents #18, #27, #28, and #40. Immediate Jeopardy was identified on 12/22/2023 and removed on 12/23/2023, but the facility remained out of compliance due to failure to protect residents from sexual abuse and failure to update care plans accordingly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure residents always had access to their individual call buttons. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from sexual abuse, including incidents of inappropriate sexual contact and kissing between residents. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to develop baseline care plans within 48 hours of admission for Resident #90. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop, update, and implement comprehensive person-centered care plans for residents exhibiting inappropriate sexual behavior, including measurable objectives and time frames. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure respiratory care was provided consistent with professional standards, including clean oxygen concentrator filters, dated humidifiers, and tubing for Residents #11 and #8. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food under sanitary conditions with proper labeling and sealing in the pantry, walk-in cooler, and freezer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by call light deficiency: 3
Residents affected by sexual abuse deficiency: 3
Staff trained on Abuse and Prevention: 30
Staff trained on Resident's Rights and Sexual Survey: 41
Facility census: 100
Staff responding to Quality Assurance Staff Questionnaire: 64
Medication dose: 5
Residents reviewed for baseline care plans: 5
Resident #90 baseline care plan completion delay: 48
Oxygen flow rate: 3
Staff trained on food safety: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Responded to sexual abuse incident on 9/7/2023, separated residents, and informed ADON. |
| CNA A | Certified Nursing Assistant | Observed sexual abuse incident on 9/7/2023 and reported to LVN D. |
| DON | Director of Nursing | Provided interviews regarding call light placement, sexual abuse incidents, care plan updates, and respiratory care. |
| ADM | Administrator | Provided interviews regarding sexual abuse incidents, care plan privacy, and food safety. |
| SS | Social Services | Participated in interviews and care plan discussions related to sexual abuse incidents. |
| NA A | Nursing Assistant | Reported knowledge of sexual behaviors and reporting requirements. |
| LVN A | Licensed Vocational Nurse | Provided information on oxygen equipment care and policy awareness. |
| LVN B | Licensed Vocational Nurse | Provided information on oxygen equipment care and policy awareness. |
| KM | Kitchen Manager | Provided information on food labeling and safety procedures. |
| DA | Dietary Aide | Provided information on food labeling and storage procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 21, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate treatment and care according to professional standards, specifically related to incomplete neurological assessments following unwitnessed falls of Resident #1 on 08/15/2023, 08/29/2023, and 09/14/2023.
Findings
The facility failed to complete and document full neurological assessments for Resident #1 after multiple unwitnessed falls, missing key assessment elements such as orientation, level of consciousness, pupil responses, pain level, and range of movement. Staff interviews and record reviews confirmed incomplete neurological checks despite facility policies requiring 72 hours of monitoring post-fall. Resident #1 sustained injuries including lacerations, bruises, and hematomas, and was hospitalized after the last fall.
Complaint Details
The investigation was complaint-related, focusing on the substantiation of incomplete neurological assessments following Resident #1's unwitnessed falls. The report documents multiple incomplete neurological checks and staff interviews acknowledging the deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and document complete neurological assessments for Resident #1 after unwitnessed falls on 08/15/2023, 08/29/2023, and 09/14/2023. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of unwitnessed falls: 3
Neurological assessments completed: 15
Neurological assessments incomplete: 22
Staff training dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Completed incident report on 08/15/2023 and provided interview about Resident #1's falls and neurological assessments. | |
| LVN B | Completed incident reports on 08/29/2023 and 09/14/2023 and provided neurological assessments and interview. | |
| CNA A | Reported finding Resident #1 on the floor on 09/14/2023 and provided interview about falls and neurological checks. | |
| DON | Director of Nursing | Provided interview regarding Resident #1's falls, neurological checks, and staff training. |
| ADM | Administrator | Notified of Resident #1's falls and expressed concern about incomplete neurological checks. |
Inspection Report
Routine
Deficiencies: 4
Aug 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, kitchen sanitation, and infection prevention and control at Colonial Manor Nursing Center.
Findings
The facility failed to ensure call lights were within reach for 3 of 9 residents reviewed, improperly stored a 50-pound bag of onions on the kitchen floor, and failed to maintain proper infection control practices during blood sugar checks for one resident. These deficiencies posed risks of unmet resident needs, potential foodborne illness, and disease transmission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents #5, #7, and #9 had call lights not within reach, risking unmet needs for assistance. | Level of Harm - Minimal harm or potential for actual harm |
| A 50-pound bag of onions was stored directly on the floor in the dry storage area, violating food storage standards. | Level of Harm - Minimal harm or potential for actual harm |
| LVN failed to properly sanitize hands and clean resident's finger before blood sugar check, risking infection transmission. | Level of Harm - Minimal harm or potential for actual harm |
| A policy on infection control was requested but not provided by the time of facility exit. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call lights: 9
Weight of improperly stored onions: 50
Residents affected by call light deficiency: 3
Residents affected by kitchen sanitation deficiency: 1
Residents affected by infection control deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in infection control deficiency for improper hand sanitizing and cleaning during blood sugar check | |
| DON | Director of Nursing | Interviewed regarding call light policy and infection control expectations |
| Dietary Manager | Interviewed regarding improperly stored onions in kitchen |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 20, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Colonial Manor Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 29, 2023
Visit Reason
The inspection was conducted as an annual survey of Colonial Manor Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 12
Sep 30, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, medication management, infection control, food safety, and staffing.
Findings
The facility was found deficient in multiple areas including failure to maintain resident confidentiality, inaccurate PASRR screening, incomplete care plan revisions, inadequate diabetic care, improper pressure ulcer care, unsafe resident supervision, failure to post nurse staffing data daily, inaccurate narcotic medication logs, poor kitchen sanitation, improper garbage disposal, and insufficient nurse aide training hours.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Potential for minimal harm: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to respect residents' right to confidentiality by leaving a computer unlocked displaying private health information of Resident #141. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide accurate PASRR Level I assessment for Resident #40 with bipolar disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise comprehensive care plans after assessments for 4 residents, including failure to address oxygen and hospice orders, incorrect feeding tube documentation, and failure to close out care plans after discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate intervention for hypoglycemic episode for Resident #32. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide proper pressure ulcer care and infection control for Resident #37, including performing wound care on the floor, contaminating gloves, and improper handling of supplies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision to prevent accidents for Residents #13, #62, and #41, including allowing possession of razors and unsupervised meals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post nurse staffing data daily for 4 days, resulting in lack of current staffing information. | Level of Harm - Potential for minimal harm |
| Failed to maintain accurate narcotic medication logs for Residents #3, #37, and #74, including failure to document medication administration timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen sanitation including rusted food racks, dirty ice machine, broken refrigerator door gasket, missing freezer thermometer, pooled water by floor drain, improper drain connections, and dirty air conditioner vent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly dispose of garbage and refuse, with dumpsters left open and soiled items and discarded furniture around dumpsters. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection prevention and control program, including improper wound care practices by RN R for Resident #37. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide required minimum 12 hours annual in-service training for 7 CNAs, lacking training in abuse, dementia, QAPI, ethics, behavioral health, falls, restraints, and emergency preparedness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 12
Training hours: 9.25
Training hours: 1
Training hours: 8.25
Training hours: 10.75
Training hours: 10.5
Training hours: 4.25
Training hours: 4.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in resident confidentiality deficiency for failing to lock computer |
| DON | Director of Nursing | Named in resident confidentiality deficiency and diabetic management interview |
| LVN D | Licensed Vocational Nurse / MDS Coordinator | Named in PASRR screening and care plan revision deficiencies |
| ADON E | Assistant Director of Nursing | Named in care plan revision and nurse staffing posting deficiencies |
| LVN P | Licensed Vocational Nurse | Named in diabetic management and medication administration deficiencies |
| RN R | Registered Nurse | Named in pressure ulcer care and infection control deficiencies |
| LVN T | Licensed Vocational Nurse | Named in pressure ulcer care deficiency |
| Nurse Aide N | Nurse Aide | Named in resident supervision deficiency |
| Nurse Aide O | Nurse Aide | Named in resident supervision deficiency |
| RN Q | Registered Nurse | Named in resident supervision deficiency |
| Speech Therapist S | Speech Therapist | Named in resident supervision deficiency |
| Food Service Supervisor | Food Service Supervisor | Named in kitchen sanitation deficiency |
| Administrator | Facility Administrator | Named in garbage disposal and nurse staffing posting deficiencies |
| ADM | Administrator | Named in CNA training deficiency interview |
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