🔎 Colonial Manor Nursing Home
Inspection Results
Inspection Overview
Colonial Manor Nursing Home has been cited for a total of 44 deficiencies since we began saving each survey.
In Minnesota, the average facility has **36.42 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: D
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.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: F
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.
Scope/Severity: F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Implement a program that monitors antibiotic use.
Scope/Severity: F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
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.
Scope/Severity: D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity: F
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: C
Keep all essential equipment working safely.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
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.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
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 necessary and PRN use is limited.
Scope/Severity: D
Implement a program that monitors antibiotic use.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**