Colonial Manor Nursing Home

FHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Deficient, Provider has date of correction (Mar 24, 2026)

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Mar 24, 2026)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Mar 24, 2026)

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Mar 24, 2026)

FHave a plan that describes the process for conducting QAPI and QAA activities.

Potential for more than minimal harm · Administration Deficiencies · Tag F0865 · Deficient, Provider has date of correction (Mar 24, 2026)

FHave the Quality Assessment and Assurance group have the required members and meet at least quarterly

Potential for more than minimal harm · Administration Deficiencies · Tag F0868 · Deficient, Provider has date of correction (Mar 24, 2026)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Mar 24, 2026)

FDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0882 · Deficient, Provider has date of correction (Mar 24, 2026)

EImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (Mar 24, 2026)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Deficient, Provider has date of correction (Mar 24, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (Mar 24, 2026)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Mar 24, 2026)

DPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Deficient, Provider has date of correction (Mar 24, 2026)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Mar 24, 2026)

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Jan 10, 2025)

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Jan 6, 2025)

FDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0882 · Deficient, Provider has date of correction (Jan 15, 2025)

EImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (Jan 10, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Deficient, Provider has date of correction (Jan 10, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Jan 10, 2025)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Jan 10, 2025)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jan 10, 2025)

DEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0661 · Deficient, Provider has date of correction (Jan 10, 2025)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Jan 10, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jan 10, 2025)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Jan 10, 2025)

EProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0725 · Complaint inspection · Deficient, Provider has date of correction (Nov 14, 2024)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Aug 30, 2024)

FMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Deficient, Provider has date of correction (Dec 1, 2023)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Dec 1, 2023)