All citations for Colonial Manor Nursing Home

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Colonial Manor Nursing Home

Last standard health inspection on record

February 6, 2025

Showing 1 to 25 of 29 citations

  1. Immediate jeopardy to resident health or safety

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (September 4, 2025).

  2. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  3. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of February 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 15, 2025).

  4. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of February 8, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 15, 2024).

  5. No harm, with potential for more than minimal harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0919, Environmental Deficiencies. Inspection of February 8, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 15, 2024).

  6. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of December 1, 2023. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 30, 2024).

  7. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of December 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 6, 2024).

  8. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of December 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 6, 2024).

  9. No harm, with potential for more than minimal harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  10. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  11. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home has a plan to correct it (September 5, 2023).

  12. No harm, with potential for more than minimal harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0362, Smoke Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  13. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0521, Services Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  14. No harm, with potential for more than minimal harm

    Have an externally vented heating system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0522, Services Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  15. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of February 8, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 5, 2023).

  16. No harm, with potential for more than minimal harm

    Assure that each resident’s assessment is updated at least once every 3 months.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0638, Resident Assessment and Care Planning Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 17, 2026).

  17. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 17, 2026).

  18. No harm, with potential for more than minimal harm

    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0568, Resident Rights Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  19. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  20. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  21. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of July 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  22. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of February 6, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 28, 2025).

  23. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of October 25, 2024. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (October 22, 2024).

  24. No harm, with potential for more than minimal harm

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0644, Resident Assessment and Care Planning Deficiencies. Inspection of December 1, 2023. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 30, 2024).

  25. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of December 1, 2023. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (January 30, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.