A list of the most recent deficiencies for Colonial Manor Care Center. 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-02 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-02 | 2024-01-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-02 | 2023-12-02 | Y |
| 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 | 2023-12-02 | 2023-12-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-02 | 2023-12-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-09 | 2023-05-10 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-13 | 2023-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-14 | 2023-04-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-14 | 2023-04-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-14 | 2023-04-28 | Y |
| 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. | Health | 2023-04-14 | 2023-04-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-14 | 2023-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-14 | 2023-04-28 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-04-14 | 2023-04-28 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-04-13 | 2023-04-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-13 | 2023-04-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-31 | 2023-04-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-10 | 2023-03-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-30 | 2022-06-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-30 | 2022-06-29 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-01-21 | 2022-02-20 | Y |
| 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. | Health | 2022-01-21 | 2022-02-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-21 | 2022-02-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-19 | 2022-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-19 | 2022-02-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-19 | 2022-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-19 | 2022-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-19 | 2022-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-19 | 2022-01-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-19 | 2022-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-01-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-23 | 2021-05-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-05-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-23 | 2021-05-23 | N |
| 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. | Health | 2021-04-23 | 2021-05-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-23 | 2021-05-23 | N |
| Dispose of garbage and refuse properly. | Health | 2021-04-23 | 2021-05-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-23 | 2021-05-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-05-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-21 | 2021-05-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-21 | Not Fixed | N |
