A list of the most recent deficiencies for Colonial Manor Nursing 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-28 | 2024-01-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-28 | 2023-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-23 | 2023-12-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-23 | 2023-12-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-23 | 2023-12-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-23 | 2023-12-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-23 | 2023-12-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-23 | 2023-12-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-08-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-18 | 2023-08-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-18 | 2023-08-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-23 | 2023-02-24 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-22 | 2022-12-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-22 | 2022-12-31 | 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 | 2022-11-22 | 2022-11-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-30 | 2022-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-30 | 2022-11-13 | 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 | 2022-09-30 | 2022-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-30 | 2022-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-13 | N |
| Post nurse staffing information every day. | Health | 2022-09-30 | 2022-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-30 | 2022-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-30 | 2022-11-13 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-30 | 2022-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-11-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-30 | 2022-11-13 | N |
| 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 | 2021-07-28 | 2021-08-30 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-07-28 | 2021-08-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-28 | 2021-08-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2021-08-24 | N |
