Deficiency Records for Colonial Manor Nursing Home
Updated as of February 01, 2019
This is not the most recent data for Colonial Manor Nursing Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-23 | 2018-07-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-23 | 2018-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-23 | 2018-07-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-24 | 2018-07-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-24 | 2018-07-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-04-24 | 2018-05-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-24 | 2018-05-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-04-24 | 2018-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-24 | 2018-05-31 | N |
| Respond appropriately to all alleged violations. | Health | 2018-04-24 | 2018-05-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-24 | 2018-05-31 | 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 | 2018-04-24 | 2018-05-31 | 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 | 2018-04-24 | 2018-05-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-04-24 | 2018-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-24 | 2018-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-10 | 2017-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-10 | 2017-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-01-10 | 2017-02-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-01-10 | 2017-02-20 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-01-18 | 2017-02-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-18 | 2017-02-20 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-01-18 | 2017-02-20 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-18 | 2017-02-20 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-01-18 | 2017-02-20 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-01-18 | 2017-02-20 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-01-18 | 2017-02-20 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-01-18 | 2017-02-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-18 | 2017-02-20 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-01-18 | 2017-02-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-18 | 2017-02-20 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-01-18 | 2017-02-20 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-18 | 2017-02-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-18 | 2017-02-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-01-18 | 2017-02-20 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-01-18 | 2017-02-20 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2017-01-18 | 2017-02-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-01-10 | 2017-01-16 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-11-01 | 2016-11-28 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-11-01 | 2016-11-28 | Y |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2016-11-01 | 2016-11-28 | Y |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-10-21 | 2015-11-30 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-10-21 | 2015-11-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-10-21 | 2015-11-30 | N |
| Properly maintained smoke detectors. | Fire Safety | 2015-10-21 | 2015-11-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-10-22 | 2015-11-30 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2015-10-22 | 2015-11-30 | N |
| Provide housekeeping and maintenance services. | Health | 2015-10-22 | 2015-11-30 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-10-22 | 2015-11-30 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2015-10-22 | 2015-11-30 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-10-22 | 2015-11-30 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-10-22 | 2015-11-30 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2015-10-22 | 2015-11-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-10-22 | 2015-11-30 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-10-22 | 2015-11-30 | N |
