Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure the dietary manager was certified to oversee nutrition and food services in the absence of a full-time RD, potentially affecting all 25 residents. The DM, employed since December 2023, was not certified and had not started certification classes. The administrator was aware but believed weekly RD visits were adequate until certification was obtained.
The facility failed to submit accurate staffing data to CMS for Q3 2024, indicating insufficient licensed nursing coverage on multiple days. Despite schedules and timecards showing coverage, the PBJ report triggered a deficiency. Staff responsible for data entry could not identify the cause, and the facility followed CMS policy.
The facility failed to ensure the acting infection preventionist (IP) had completed specialized training, affecting all 25 residents. The DON, who started in July 2024, had only completed one module of the CDC course, while RN-A, the MDS coordinator, had no training. Both were enrolled in the necessary courses, but the facility lacked a trained IP, contrary to its Infection Prevention and Control Program requirements.
The facility failed to implement a process for reviewing antibiotic use, affecting several residents. Infection control logs lacked information on antibiotic dosages and infection resolution. The newly assigned Infection Preventionist had not started training, and the facility's policies on antibiotic stewardship were not adequately enforced.
A resident with moderately impaired cognition reported missing handkerchiefs and shirts, but the facility failed to follow its grievance process. Despite informing staff, no formal report was completed, and confusion among staff about the procedure was evident. The absence of a social worker and a missing belongings binder contributed to the breakdown in handling the grievance.
A facility failed to accurately code a resident's hospice status on the MDS assessment. The resident, with diagnoses of protein-calorie malnutrition and receiving palliative care, was enrolled in hospice care, but this was not reflected in the quarterly MDS. The MDS nurse acknowledged the oversight after reviewing the resident's EMR and admitted to inadvertently missing the hospice status. The facility's policy for MDS accuracy was requested but not provided.
A facility failed to update a resident's care plan to include hospice care, despite the resident being enrolled in hospice services. The resident had diagnoses of protein-calorie malnutrition and was receiving palliative care. Although a provider had ordered hospice admission and the hospice agency confirmed enrollment, the care plan did not reflect these services. The MDS nurse acknowledged the oversight, which was contrary to the facility's care planning policy requiring updates with any changes.
A resident was discharged without a complete recapitulation of stay, as required by facility policy. The resident, with conditions including a pressure ulcer and paraplegia, was discharged home with their spouse. Despite discharge orders being reviewed, the medical record lacked a discharge summary due to staff turnover and lack of awareness by the MDS coordinator.
The facility failed to accurately monitor and document the weights of two residents, leading to a deficiency in providing adequate nutrition. One resident experienced significant weight loss without proper documentation or physician notification, while another had inconsistent weight records that were not addressed. The facility's policy for weight monitoring was not followed, contributing to the deficiency.
A facility failed to follow enhanced barrier precautions (EBP) for a resident with a urinary ostomy. The resident required assistance for daily activities, including toileting. An NA was observed assisting the resident without donning the required PPE, despite an EBP sign on the door. The NA believed PPE was unnecessary as she did not touch the resident directly. The DON confirmed that the facility's policy required PPE during toileting for residents under EBP, and the infection preventionist noted that EBP had been reviewed in a staff meeting attended by the NA.
The facility failed to document and administer pneumococcal and influenza vaccines for residents, despite having policies in place. A resident's record lacked documentation of receiving vaccines or education on risks/benefits, while another resident's record showed consent but no administration of the influenza vaccine. The RN confirmed delays in obtaining consents and that no influenza vaccines had been given, despite availability.
A facility failed to report a verbal abuse allegation involving a resident to the administrator and State Agency (SA) in a timely manner. The incident, where a nursing assistant allegedly threatened a resident, was delayed in reporting due to the absence of key staff and unsuccessful attempts to delegate reporting duties. The facility's policy requires immediate reporting, but the incident was not reported to the SA until the following day.
The facility failed to provide sufficient staffing, resulting in delayed assistance with personal care needs for several residents. Residents reported extended wait times for toileting and other care, leading to incontinence and missed baths. Staff interviews confirmed the shortage, and administration acknowledged the issue but lacked a process to track call light response times.
A resident with severe cognitive impairment and Alzheimer's disease experienced a change in their ADLs, including coughing or choking during meals and weight loss. Despite these changes, the care plan was not updated to include the Speech Language Pathologist's orders for staff assistance with feeding and cues to sit up. Interviews with staff confirmed the resident ate better with assistance, but the care plan remained unchanged, leading to a deficiency.
A resident entered the facility without a pressure ulcer but later developed one due to inadequate assessment and intervention. The facility failed to update the care plan, conduct comprehensive assessments, and follow physician orders for dressing changes. The resident was not placed on the wound clinic list, and the facility's actions did not align with their policy to prevent and treat pressure ulcers.
A resident with severe cognitive impairment experienced a decline in continence due to the facility's failure to implement an effective toileting program. Despite being identified as a good candidate for retraining, the resident's care plan was not consistently followed, and no causal analysis was conducted. The DON acknowledged the decline but lacked a treatment plan, contributing to the deficiency.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) was certified to oversee nutrition and food services in the absence of a full-time registered dietician (RD). This deficiency had the potential to affect all 25 residents residing in the facility. During an interview, DM-J, who had been employed since December 2023, admitted she was not a certified dietary manager and had not started any certification classes. Although she held a Food Safety Certificate from 2019, she was only notified on the day of the interview that the administrator would enroll her in the certification class. The administrator acknowledged awareness of DM-J's lack of certification and believed that the RD's weekly visits would suffice until DM-J obtained her certification. However, DM-J had not yet been signed up for the dietary certification classes. The job description for the dietary manager required knowledge of state and federal food regulations, Serv-Safe Certification, and a current certification as a Certified Dietary Manager (CDM) or dietician, or a willingness to obtain such certification.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024. The CMS payroll-based journal (PBJ) staffing data report indicated that there were four or more days within the quarter where the facility had less than 24 hours per day of licensed nursing coverage. The specific dates identified were 5/25/24, 6/8/24, 6/9/24, 6/16/24, 6/1/24, 6/22/24, 6/23/24, 6/24/24, 6/29/24, and 6/30/24. However, upon review of the nursing staff schedules and daily staffing postings for these dates, it was found that a licensed nurse was scheduled for each shift, and timecards confirmed that all shifts were worked by either an employed nurse or an agency nurse. Interviews with the nursing department coordinator and the business office manager revealed that there was always a licensed nurse working each shift, and all nursing staff, including management and agency staff, were entered into the PBJ report. Despite this, the report still triggered for insufficient coverage. The business office manager, who was responsible for entering the data, and the administrator could not determine why the report indicated a deficiency. The facility stated that they followed the CMS PBJ - LTC policy manual, but the issue with the report remained unresolved.
Lack of Trained Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which had the potential to affect all 25 residents residing in the facility. The Director of Nursing (DON), who started her employment in July 2024, assumed the infection control role in October but had only completed one module of the CDC infection preventionist course. The role was intended to be shared with RN-A, the Minimum Data Set (MDS) coordinator, who had no training at the time of the survey. RN-A, who began working at the facility in June 2024, was initially focused on MDS training and had not yet started the CDC infection preventionist course, although she was enrolled. The facility's administrator acknowledged the lack of a trained infection preventionist but noted that both the DON and RN-A were enrolled in the necessary training. The facility's Infection Prevention and Control Program, dated December 2022, outlined the need for effective oversight and training in infection prevention and control practices, which was not being met at the time of the survey.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a comprehensive process for reviewing antibiotic use, which affected four out of five residents reviewed for antibiotics. The monthly infection control logs from July to November 2024 identified residents with infections who were administered antibiotics, but these logs lacked critical information such as antibiotic dosages and whether the infections had resolved. For instance, one resident with a urinary tract infection (UTI) was prescribed Macrobid, but the surveillance log did not indicate the dosage or resolution of the infection. Similarly, other residents with UTIs were prescribed antibiotics like ampicillin and cefdinir, yet the logs did not document the resolution of their infections. Interviews revealed that the facility's registered nurse, who was newly assigned as the Infection Preventionist (IP), had not yet started her IP training and was unaware of the existing processes for antibiotic use identification. The facility's administrator expected the nursing team to track and maintain monthly updates on antibiotic use, but this was not consistently enforced. The facility's Antibiotic Stewardship Policy required follow-up on pending cultures and monitoring of antibiotic usage patterns, but these procedures were not adequately implemented, leading to the deficiency in antibiotic management.
Failure to Follow Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to adhere to its grievance process regarding missing personal property for a resident identified as R19, who reported missing handkerchiefs and shirts. R19, who has moderately impaired cognition, stated that multiple packs of handkerchiefs and a couple of shirts have been lost since his admission in January 2024. Despite informing multiple staff members about the missing items, no formal grievance process was initiated. Interviews with nursing assistants and the nursing department coordinator revealed confusion and lack of clarity about the procedure for handling missing belongings, with some staff unsure of the next steps after reporting to the charge nurse. Further investigation showed that the facility's policy required a missing or damaged item report to be completed and submitted to social services, who would maintain a file of such reports. However, the administrator confirmed that no form was completed for R19's missing items, indicating a failure to follow the grievance process. The laundry staff was aware of the missing handkerchiefs but not the shirts, and no resolution was reached. The absence of a social worker further complicated the process, as the missing belongings binder was not maintained, leading to a breakdown in the facility's grievance handling procedure.
Failure to Accurately Code Hospice Status on MDS
Penalty
Summary
The facility failed to accurately code a resident's hospice status on the Minimum Data Set (MDS) assessment. The resident, identified as R15, had diagnoses of protein-calorie malnutrition and was receiving palliative care. Despite being enrolled in hospice care on July 8, 2024, as confirmed by the hospice agency, the quarterly MDS assessment did not reflect this status. The MDS nurse, RN-A, acknowledged during an interview that hospice was not marked in Section O of the MDS assessment, which should indicate special treatments, procedures, and programs. This oversight was identified when RN-A reviewed the resident's electronic medical record and admitted to inadvertently missing the hospice status. The facility's policy for the accuracy of MDS assessments was requested but not provided.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R15, to include hospice care, despite the resident being enrolled in hospice services. R15's facesheet, printed on 11/20/24, listed diagnoses of protein-calorie malnutrition and an encounter for palliative care. The quarterly Minimum Data Set (MDS) assessment indicated that R15 had moderately impaired cognition but could communicate effectively. Progress notes from 7/3/24 showed that a provider had faxed an order for hospice admission, and the hospice agency confirmed R15's enrollment in hospice services on 7/8/24. However, R15's care plan, initiated on 5/1/23, did not reflect the inclusion of hospice or palliative care. During an interview, the MDS nurse acknowledged the omission and stated that the care plan should have been updated to reflect the resident's hospice status. The facility's care planning policy, revised in 8/23, requires care plans to be updated with any changes throughout a resident's stay.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to document a complete recapitulation of stay for a resident reviewed for discharge. The resident, who was admitted to the facility with diagnoses including a pressure ulcer, depression, osteomyelitis, and paraplegia, was discharged to home with their spouse. Although discharge orders were signed by the provider and reviewed with the resident and spouse, the medical record lacked a discharge summary. Interviews with facility staff revealed that there was confusion regarding the responsibility for completing the discharge summary. The regional director of skilled care confirmed the absence of the discharge summary and attributed it to staff turnover. The MDS coordinator, who was handling the discharge process for the first time, was unaware of the requirement to complete a discharge summary, resulting in its omission. The facility's policy required nursing staff to complete the discharge summary in the electronic health record, but this was not adhered to in this instance.
Failure to Accurately Monitor and Document Resident Weights
Penalty
Summary
The facility failed to document and monitor weight loss for a resident, R24, who experienced significant weight loss. R24 had a history of stroke, Parkinsonism, dementia, and dysphagia, which placed her at risk for nutritional compromise. Despite these risks, the facility did not accurately monitor her weight changes, as evidenced by inconsistent weight records and a lack of reweighs when discrepancies were noted. The registered dietician (RD) and licensed practical nurse (LPN) both identified inaccuracies in the weight records, but reweighs were not conducted, and the physician was not notified of the significant weight loss. Additionally, the facility failed to obtain accurate weights for another resident, R4, who had severe protein-calorie malnutrition and dysphagia. R4's weight records showed inconsistencies, with an aberrant weight recorded that was not addressed. The RD noted the inaccuracies in her reports, but there was no communication with the nursing staff or director of nursing (DON) to rectify the issue. The DON was aware of the inaccuracies but relied on verbal communication to address the problem, which did not effectively resolve the issue. The facility's policy required weekly weights to be taken by nursing staff and entered into the electronic medical record, with reweighs requested for significant changes. However, this policy was not followed, as evidenced by the lack of reweighs and physician notification for significant weight changes. The facility's failure to adhere to its policy and ensure accurate weight monitoring contributed to the deficiency in providing adequate nutrition and monitoring for residents at risk of malnutrition.
Failure to Follow Enhanced Barrier Precautions for Resident with Urinary Ostomy
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident with a urinary ostomy. The resident, who had diagnoses including neuromuscular dysfunction of the bladder and bladder-neck obstruction, required staff assistance for most activities of daily living, including toileting. An observation revealed that a nursing assistant (NA) entered the resident's room and assisted with toileting without donning the required personal protective equipment (PPE), despite an EBP sign on the door indicating the need for gown, gloves, and mask. During interviews, the NA admitted to not wearing PPE while assisting the resident, believing it was unnecessary as she did not touch the resident directly. The director of nursing (DON) was uncertain about the distance requirement for PPE use and later confirmed that the facility's policy required PPE during toileting for residents under EBP. The infection preventionist confirmed that EBP had been reviewed in a staff meeting, and the NA had attended. The facility's policy indicated that EBP should be used for residents with indwelling medical devices during high-contact care activities such as toileting.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to maintain proper records and documentation for pneumococcal and influenza vaccinations for residents, leading to a deficiency in their immunization protocol. Specifically, one resident's medical record lacked documentation of receiving any pneumococcal or influenza vaccines, as well as documentation of education on the risks and benefits or declination of these vaccines. Additionally, another resident's record showed consent for the influenza vaccine, but there was no documentation of the vaccine being administered, despite the COVID vaccine being given. Furthermore, the facility did not document that the influenza vaccine had been offered or that education on risks and benefits was provided for another resident. The registered nurse (RN) confirmed that the facility had not administered influenza vaccines for the current year, citing delays in receiving consent forms from families. The RN also acknowledged that the influenza vaccines had been available at the facility for several months but had not been administered. The facility's policies on resident vaccinations and infection control outlined the procedures for offering and documenting vaccinations, including providing educational handouts and obtaining consent. However, these procedures were not followed, resulting in the deficiency.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the administrator and the State Agency (SA) in a timely manner. The incident occurred when a nursing assistant allegedly threatened a resident by saying that her husband would yell at her if she did not cooperate. This event was reported internally by another nursing assistant who witnessed the incident, but the report was delayed due to the absence of the charge nurse, the Director of Nursing (DON), and the administrator. The business office manager was informed later in the day, but the report to the SA was not made until the following day. The facility's Abuse Prevention Plan requires that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. In this case, the report was delayed beyond the required timeframe, as the administrator was out of the building and the DON was unavailable to report the incident. The delay in reporting was further compounded by unsuccessful attempts to grant another staff member the privileges needed to report to the SA, resulting in a failure to comply with the facility's policy and regulatory requirements.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, resulting in delayed assistance with personal care needs. Seven residents reported concerns about inadequate staffing, leading to extended wait times for assistance with toileting and other personal care tasks. For instance, one resident experienced a 1.5-hour wait for assistance, resulting in incontinence due to diarrhea. Another resident reported sitting on the commode for an hour, causing discomfort and increasing the risk of urinary tract infections due to delayed catheter drainage. The call light logs for the residents indicated numerous instances of prolonged wait times, with some residents experiencing waits of over an hour. Interviews with family members and residents highlighted the impact of these delays, including embarrassment, frustration, and anxiety. Residents expressed concerns about missed baths and the inability to receive timely assistance, which affected their dignity and personal hygiene. The facility's staff also acknowledged the staffing shortages, with some employees stating that they were unable to respond to call lights promptly due to other responsibilities. The facility's administration recognized the staffing challenges but did not have a clear process for tracking and addressing call light response times. The Director of Nursing was unaware of a specific time frame for what constituted a timely response, and the interim case manager noted that staffing was based on census rather than the acuity of residents' needs. Despite efforts to recruit new staff, the facility continued to struggle with providing adequate care, as evidenced by the residents' complaints and the documented call light wait times.
Failure to Revise Care Plan for Resident with ADL Changes
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in their activities of daily living (ADLs). The resident, who had severe cognitive impairment due to Alzheimer's disease and anxiety, initially required partial to substantial assistance with ADLs and showed no signs of a swallowing disorder. However, a significant change in the resident's condition was noted, including coughing or choking during meals and a weight loss from 178 to 160 pounds. Despite these changes, the care plan was not updated to reflect the new needs identified by the Speech Language Pathologist (SLP), which included staff assistance with feeding at every meal and frequent cues to sit up. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Nursing Assistant (NA), revealed that while the resident could feed themselves, they ate better when assisted by staff. The Director of Nursing (DON) acknowledged that the care plan had not been revised to include the SLP's orders and noted the resident's weight loss. The facility's care plan policy requires that care plans be revised as necessary to reflect changes in a resident's condition, but this was not done in this case, leading to the deficiency.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement person-centered interventions to prevent a pressure ulcer for a resident who entered the facility without a pressure ulcer. Initially, the resident was assessed with a Braden Scale score indicating no risk for pressure ulcers, but later assessments showed an increased risk. Despite this, the care plan did not adequately address the resident's needs, and interventions such as a pressure-reducing device were not effectively implemented. The resident developed a pressure ulcer on the coccyx, which was not promptly or adequately addressed. There was a lack of comprehensive pressure ulcer assessments, including staging, characteristics, and signs of infection. The facility also failed to conduct a tissue tolerance test to determine repositioning frequency and did not perform daily skin monitoring or weekly comprehensive wound assessments. The care plan was not updated to reflect the development of the pressure ulcer or to prevent further occurrences. The facility's policy required individualized repositioning programs and regular monitoring of skin conditions, but these were not followed. The resident's dressing was not changed according to physician orders, and the resident was not placed on the wound clinic list for weekly measurements. The Director of Nursing acknowledged the need for improvement in pressure ulcer care, but the facility's actions did not align with their policy to prevent and treat pressure ulcers effectively.
Failure to Implement Effective Toileting Program
Penalty
Summary
The facility failed to develop an individualized toileting program for a resident with severe cognitive impairment, Alzheimer's disease, and anxiety, leading to a decline in continence. The resident required partial to moderate assistance with toileting and was frequently incontinent of bladder but always continent of bowel upon admission. Despite being identified as a good candidate for a bowel/bladder retraining program, the facility did not implement an effective toileting plan, and the resident's continence declined over time. The resident's care plan included a toileting schedule to prevent bladder incontinence, but the plan was not consistently followed. The resident was supposed to be toileted three times a day, but records showed inconsistencies in adherence to this schedule. Additionally, the facility did not maintain a voiding diary or conduct a causal analysis to understand the resident's baseline toileting routine, which could have informed a more effective care plan. The Director of Nursing (DON) acknowledged the resident's decline in continence but was unable to articulate a treatment plan to address the issue. The facility's policy required a comprehensive assessment and care plan to maintain the highest practicable level of continence, but this was not achieved. The lack of a revised toileting plan and failure to notify the physician of the resident's decline contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Jackson | 9.4 mi | — | 0 | 0 |
| Good Samaritan Society - Windom | 12.5 mi | — | 23 | 1 |
| Aspire Of Lake Park | 17.4 mi | — | 0 | 0 |
| Accura Healthcare Of Spirit Lake | 18.4 mi | — | 9 | 0 |
| Good Samaritan Society - Mountain Lake | 21.2 mi | — | 3 | 0 |
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