Inspection Results » Colonial Manor Care Center

  1. Health Inspection on February 26, 2019 [1]

    1. Widespread: Immediate jeopardy to the resident health or safety
      • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-03-26)
      • 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. (Corrected 2019-03-26)
    2. Isolated: Actual harm that is not immediate jeopardy
      • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2019-03-26)
      • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2019-03-26)
    3. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2019-03-26)
      • Dispose of garbage and refuse properly. (Corrected 2019-03-26)
    4. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-03-26)
      • Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. (Corrected 2019-03-26)
      • 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 (Corrected 2019-03-26)
      • Keep all essential equipment working safely. (Corrected 2019-03-26)
      • Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (Corrected 2019-03-26)
      • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-03-26)
      • Keep residents' personal and medical records private and confidential. (Corrected 2019-03-26)
      • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-03-26)
      • Assist a resident in gaining access to vision and hearing services. (Corrected 2019-03-26)
      • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-03-26)
    5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2019-03-26)
      • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-03-26)
      • 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 (Corrected 2019-03-26)
      • 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. (Corrected 2019-03-26)
      • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-03-26)
      • Respond appropriately to all alleged violations. (Corrected 2019-03-26)
      • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2019-03-26)
      • Ensure each resident receives an accurate assessment. (Corrected 2019-03-26)
      • Reasonably accommodate the needs and preferences of each resident. (Corrected 2019-03-26)
      • 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. (Corrected 2019-03-26)
      • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-03-26)
      • Provide or get specialized rehabilitative services as required for a resident. (Corrected 2019-03-26)
      • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-03-26)
      • 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. (Corrected 2019-03-26)

  2. Health Inspection on February 22, 2019 [1]

    1. Pattern: Immediate jeopardy to the resident health or safety
      • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-02-23)

To be part of the Medicare and Medicaid programs, nursing homes have to meet certain requirements set by Congress. The Centers for Medicare and Medicaid Services (CMS) has entered into an agreement with state governments to do health inspections and fire safety inspections of these nursing homes and investigate complaints about nursing home care. [2]

About The Inspection Process


References

  1. http://www.medicare.gov/NursingHomeCompare/About/Health-Inspections.html
  2. http://www.medicare.gov/NursingHomeCompare/About/Inspection-Results.html