COLONIAL MANOR NURSING HOME, INC

Nursing Home Inspector

1815 EAST SKELLY DRIVE
TULSA, OK 74105
Tulsa County
Phone: 918-743-7838
Provider Number: 375465
Last Inspection: 01/18/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 72
Beds Available: 48
Percent Occupancy: 60%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

67

Facility
25

County
26

OK
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

67

2017
41

2015
114

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/18/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 2/20/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/20/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 2/20/2017
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Minimal 4 2/20/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Actual 5 2/20/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 2/20/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Minimal 4 2/20/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 2/20/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 2/20/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 2/20/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Actual 5 2/20/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/20/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 2/20/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 2/20/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 2/20/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 2/20/2017
 

10/22/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 11/30/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Minimal 4 11/30/2015
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 11/30/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 11/30/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 11/30/2015
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 11/30/2015
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Minimal 4 11/30/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 11/30/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 11/30/2015
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 11/30/2015
 

8/4/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. Pattern : Minimal 4 9/26/2014
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 9/26/2014
 
Failed To: 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. Pattern : Minimal 4 9/26/2014
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 9/26/2014
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 12/19/2014
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 9/26/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 9/26/2014
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 9/26/2014
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 9/26/2014
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 9/26/2014
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 9/26/2014
 
Failed To: Provide residents with private access to a telephone. Pattern : Minimal 4 9/26/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/26/2014
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 9/26/2014
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Minimal 4 9/26/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/19/2014
 
Failed To: Provide proof that residents' personal money that is deposited with the nursing home is secure. Pattern : Minimal 4 9/26/2014
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Actual 5 9/26/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 9/26/2014
 
Failed To: Keep complete, dated laboratory records in the resident's file. Isolated : Minimal 3 9/26/2014
 
Failed To: Send unopened mail from residents and promptly deliver unopened mail to residents. Widespread : Minimal 5 9/26/2014
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 9/26/2014
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 9/26/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 9/26/2014
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 9/26/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 9/26/2014
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 9/26/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 9/26/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

11/1/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 11/28/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 11/28/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern : Minimal 4 11/28/2016
 

6/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 7/10/2015
 

3/16/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 4/10/2015
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Actual 4 4/10/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/10/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OK State Avg
Number of Residents 72 76.97 61.05
Registered Nurses 0.38 0.50 0.47
Licensed Practical / Vocational Nurses 0.99 0.95 0.83
Certified Nursing Assistants 2.98 2.71 2.47
Total Staff Hours 4.35 4.15 3.77

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OK State Avg%
of high risk long-stay residents with pressure ulcers 9 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 34 89 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 75 94 95
of long-stay residents experiencing one or more falls with major injury 11 5 5
of long-stay residents who have depressive symptoms 5 5 5
of long-stay residents who lose too much weight 4 9 8
of long-stay residents who received an antianxiety or hypnotic medication 18 23 29
of long-stay residents who received an antipsychotic medication 10 14 19
of long-stay residents who self-report moderate to severe pain 14 8 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 20 15
of long-stay residents whose need for help with daily activities has increased 20 17 15
of long-stay residents with a catheter inserted and left in their bladder 4 2 2
of long-stay residents with a urinary tract infection 0 4 5
of low risk long-stay residents who lose control of their bowels or bladder 16 42 34
of short-stay residents assessed and appropriately given the pneumococcal vaccine 15 78 79
of short-stay residents who had an outpatient emergency department visit 11 12 16
of short-stay residents who made improvements in function 69 65 64
of short-stay residents who newly received an antipsychotic medication 0 2 2
of short-stay residents who self-report moderate to severe pain 19 17 20
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 32 74 74
of short-stay residents who were rehospitalized after a nursing home admission 23 23 23
of short-stay residents who were successfully discharged to the community 60 51 48
of short-stay residents with pressure ulcers that are new or worsened 4 1 1