A list of the most recent deficiencies for Colonial Manor Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-01 | 2024-01-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-01 | 2024-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-30 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-12-01 | 2024-01-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-07 | 2023-09-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-08 | 2023-05-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-08 | 2023-05-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Have an externally vented heating system. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-07 | 2023-05-05 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-02-08 | 2023-04-28 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-06 | 2022-01-25 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide appropriate foot care. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-09 | 2022-01-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-12-09 | 2022-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-09 | 2022-01-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-22 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-12-09 | 2022-01-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-09 | 2022-01-22 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-09 | 2022-01-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-14 | 2021-07-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-14 | 2021-07-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-14 | 2021-07-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-14 | 2021-07-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-14 | 2021-07-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-19 | 2019-10-01 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Have an externally vented heating system. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-07-19 | 2019-09-16 | N |
