Most Recent Deficiencies for COLONIAL MANOR CARE CENTER

Updated as of April 01, 2020

The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

The tables below are too small to fit on a phone. More information can be seen using a larger device such as a tablet, laptop, or desktop computer.

Deficiency Deficiency Date
Inspect, test, and maintain automatic sprinkler systems. 2020-02-26
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. 2020-02-26
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. 2020-02-26
Have generator or other power source capable of supplying service within 10 seconds. 2020-02-26
Create arrangements with other facilities to receive patients. 2019-02-05
Keep aisles, corridors, and exits free of obstruction in case of emergency. 2019-02-05
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. 2019-02-05
Inspect, test, and maintain automatic sprinkler systems. 2019-02-05
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. 2019-02-05
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. 2019-02-05
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. 2019-02-05
Develop and maintain an Emergency Preparedness Program (EP). 2018-01-31
Inspect, test, and maintain automatic sprinkler systems. 2018-01-31
Properly select, install, inspect, or maintain portable fire extinguishes. 2018-01-31
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. 2018-01-31
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. 2018-01-31
Keep all essential equipment working safely. 2019-09-26
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2019-09-06
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2019-07-11
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 2019-05-24
Provide appropriate treatment and care according to orders, resident?s preferences and goals. 2019-05-24
Develop and implement policies and procedures to prevent abuse, neglect, and theft. 2020-02-28
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. 2020-02-28
Ensure each resident receives an accurate assessment. 2020-02-28
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2020-02-28
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2020-02-28
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 2020-02-28
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2020-02-28
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. 2019-02-22
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2019-02-22
Provide care and assistance to perform activities of daily living for any resident who is unable. 2019-01-11
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 2019-01-11
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 2019-01-11
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2018-04-04
Keep all essential equipment working safely. 2018-04-04
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. 2019-02-26
Reasonably accommodate the needs and preferences of each resident. 2019-02-26
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. 2019-02-26
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 2019-02-26
Keep residents' personal and medical records private and confidential. 2019-02-26
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 2019-02-26
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. 2019-02-26
Respond appropriately to all alleged violations. 2019-02-26
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. 2019-02-26
Ensure each resident receives an accurate assessment. 2019-02-26
Provide care and assistance to perform activities of daily living for any resident who is unable. 2019-02-26
Assist a resident in gaining access to vision and hearing services. 2019-02-26
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 2019-02-26
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 2019-02-26
Provide safe, appropriate pain management for a resident who requires such services. 2019-02-26
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install 2019-02-26
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. 2019-02-26
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. 2019-02-26
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 2019-02-26
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. 2019-02-26
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. 2019-02-26
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2019-02-26
Dispose of garbage and refuse properly. 2019-02-26
Provide or get specialized rehabilitative services as required for a resident. 2019-02-26
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 2019-02-26
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. 2019-02-26
Keep all essential equipment working safely. 2019-02-26
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2019-02-26
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 2019-02-26
Provide medically-related social services to help each resident achieve the highest possible quality of life. 2019-02-26
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 2019-02-26
Develop and implement policies and procedures to prevent abuse, neglect, and theft. 2019-02-22
Protect each resident from mistreatment, neglect and misappropriation of personal property. 2017-11-03
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 2017-11-03
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. 2017-11-03
Ensure each resident receives an accurate assessment by a qualified health professional. 2017-11-03
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2017-11-03
Provide care by qualified persons according to each resident's written plan of care. 2017-11-03
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 2017-11-03
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 2017-11-03
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . 2017-11-03
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 2017-11-03
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 2017-08-18
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 2017-08-01
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. 2018-02-02
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. 2018-02-02
Ensure each resident receives an accurate assessment. 2018-02-02
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2018-02-02
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. 2018-02-02
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 2018-02-02
Provide enough food/fluids to maintain a resident's health. 2018-02-02
Provide safe and appropriate respiratory care for a resident when needed. 2018-02-02
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. 2018-02-02
Ensure that the resident and his/her doctor meet face-to-face at all required visits. 2018-02-02
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. 2018-02-02
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 2018-02-02
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 2018-02-02
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 2018-02-02
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2018-02-02
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2018-02-02
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 2018-02-02
Provide and implement an infection prevention and control program. 2018-02-02
Develop and implement policies and procedures for flu and pneumonia vaccinations. 2018-02-02
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2018-02-02
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. 2018-02-02
Keep each resident free from physical restraints, unless needed for medical treatment. 2017-01-12
Store, cook, and serve food in a safe and clean way. 2017-01-12
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 2017-01-12
Have a program that investigates, controls and keeps infection from spreading. 2017-01-12
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2017-01-12
Provide appropriate treatment and care according to orders, resident?s preferences and goals. 2018-01-22