Colonial Manor Nursing Home
Colonial Manor Nursing Home in LAKEFIELD, MN — inspection on January 29, 2026.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
on 11/18/25. R31 was provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary
provided with the CMS-10123 Notice of Medicare Non-Coverage on 11/18/25 at which time R31 had signed the notice. R31 was not provided with adequate time to appeal the decision and make a request for an independent reviewer authorized by Medicare to review the decision to end the services if R31 had wanted to.
Interview on 1/28/26 at 3:13 p.m., with the regional administrator identified that residents were to be given 2-day notice before Medicare part A skilled services were to end.
Her expectation was that the facility would provide timely notices to residents who were ending Medicare part A skilled services to ensure the resident had time to appeal the decision if they wanted to. A policy was requested but not received.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
bed-hold policies.
(R31) sampled residents.
Findings include: R31's 12/12/25, accepted discharge Minimum Data Set
care, and participated in speech, occupational and physical therapy. R31 had been discharged to home/community. R31's 11/20/25, progress notes identified that R31 was excited to return to the assisted living facility.
Staff reviewed the discharge summary with R31 and faxed R31's discharge orders to the pharmacy. R31's 11/21/25, progress note identified R31 discharged via private vehicle accompanied by caregiver.
There was no recapitulation of R31's stay documented in the progress notes. R31's 11/21/25, Transition of Care/Discharge Summary form identified a section on the form to document a recapitulation of R31's stay which was left blank.
Interview on 1/29/26 at 1:08 p.m., with director of nursing (DON) identified there was a place on the facilities Transition of Care/Discharge Summary form to document the resident's recapitulation of stay.
She confirmed that the section on R31's discharge form titled recapitulation of stay had not been completed.
She further revealed that there had not been a discharge summary documented for R31's stay while at the nursing home on the discharge form or in the progress notes.
She was unaware that the facility needed to complete a summary of the resident's stay in addition to the discharge information provided to the accepting facility on the discharge form.A policy was requested but not provided by end of survey.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
therapy room and the unsecured door to the hall accessing kitchen, basement stairs, and the assisted
persons had not been identified and presented a potential hazard if a wandering resident were to
policy Elopement identified it was the responsibility of all staff to assist in investigation of a reported missing resident,.
The policy failed to include any reference to monitoring a resident who attempted to access unauthorized areas, or response to residents utilizing a wander guard device and attempting to access alarmed exits or restricted areas. No additional policies or procedures were provided during the survey period.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of April 2025, Departmental Supervision, Nursing policy identified that the facility would have a licensed nurse (registered nurse, or licensed practical or vocational nurse) on duty 24 hours a day 7 days per week.
The policy further identified that an RN would be scheduled to work 8 consecutive hours in a 24-hour period, 7 days a week.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Observation on 1/28/26 at 2:53 p.m., of the Colonial Manor Nursing Home daily staffing posting identified there was no facility census documented on the form.
Observation on 1/29/26 at 12:24 p.m., of the Colonial Manor Nursing Home daily staffing posting identified there was no facility census documented on the form.
Interview on 1/29/26 at 3:00 p.m., with the business office manager identified that the night nurse filled out the daily staffing posting form.
The form was to include the facility current census.
Review of the daily staff postings from 1/1/26 through 1/29/26 revealed that the census section had been left blank on each day.
Review of the undated Nurse Staffing Information and Daily Census policy identified that the facility must post daily the following information: the facility name, current date, total number and actual hours worked by title and license, and the resident census.
The posting must be placed in a prominent place and be easy to read.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
the food and nutrition service, including a qualified dietician.
person to serve as the director of food service to oversee the dietary department in the absence of a
food from the kitchen.Findings include: Interview on 1/27/26 at 9:30 a.m. with the dietary manager (DM), identified she was not yet certified and was waiting for direction as to what courses she needed to complete to obtain her certification.
She reported she did have her SERV Safe certification and had previously worked as the main cook, prior to taking the position as DM.
She reported the facility had a contracted registered dietitian that came to the facility once a week on Tuesdays and was available via phone or email between visits.
She identified when the RD came to the facility, she completed the assessments, reviewed dietary items with her, and assigned leaning topics she was to complete online.
She reported she had not had anyone work alongside her to provide training in her new role, but she was committed to taking the courses and obtaining her certification.
Interview on 1/28/26 at 3:40 p.m. with the RD reported she came to the facility once a week, on Tuesdays to complete the Minimum Data Set (MDS) assessments, review menus, and assist the DM.
She reported the DM completed the initial interview with residents to determine preferences, and general information that was documented in the record.
Interview on 1/28/26 at 4:09 p.m. with the administrator and the regional director reported they were under the impression that the DM's years of experience met the requirement for the certified dietary manager position.
They both confirmed the intent for the DM to complete the required certification coursework, but she had not started as of the date of survey.
Following discussion and review of the regulation identified in the State Operation Manual (SOM) they voiced agreement that the facility was not currently in compliance with the regulation. A policy for management of the dietary department was requested but not provided by the end of the survey.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Observation and interview on 1/27/26 at 11:15 a.m. with the administrator noted the areas of concern and confirmed the need for development of cleaning schedules and maintenance would be notified of the need to clean the vents in the kitchen on a regular basis. A policy was requested for cleaning of the kitchen and equipment but not provided by the end of the survey period.
245572 01/29/2026
Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of the above dates and facility staff timecard punches for the dates identified, showed that the facility did have licensed staff on duty each shift on each day identified.
Interview on 1/27/26 at 3:15 p.m., with the regional director of skill operations identified there had been PBJ issues at each of the facilities she consulted.
She reported the facility had not been without 24 hours licensed nursing staff and she was unsure why that had triggered for the facility.
The business office manager was responsible for submitting the PBJ data and she also completed audits on the data she submitted.
Interview on 1/29/26 at 1:30 p.m., with business office manager confirmed she was responsible for submitting the facility PBJ data.
She revealed she had not previously reviewed the 1702D report until it had been requested during this survey.
She found with the review that one of the full time licensed practical nurses (LPN)-B was not pulling from their payroll system into the PBJ report. LPN-B worked most of the days in question.
She was still investigating why the report had been triggered on the other days.
She confirmed that there had been inaccurate PBJ reporting completed.
Review of the undated, Payroll Based Journaling (PBJ) policy identified the facility would regularly compile and submit PBJ reports that provided data on staffing levels.
The facility would use attendance software databased to assist with reporting.
The facility would verify submission by checking the validation report once submitted.
The facility could take steps to streamline workflow to help track staffing-related data.
Use automated payroll processes, implement processes for staff to clock-in and clock-out for hourly tracking, adopt in-house systems that automatically generate reports, regularly audit PBJ files and data prior to submitting reports, and train and educate staff involved in PBJ data collection and submission.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of the July 2025, Quality
from input from caregivers, residents, health practitioners, families and other stakeholders.
Data may
facility would set goals and measure progress towards those goals.
The administrator was responsible for overseeing the QAPI committee.
The committee will decide on what data to monitor with priority given to QA committee project recommendations.
The QAPI team will review information from sources to determine if gaps or patterns exist in the facility systems of care that could result in quality problems and if there were opportunities to make improvements.
Once a concern or issue was identified the QAPI team would prioritize and determine which problem will become the focus for a performance improvement project (PIP).
The facility will then outline who would be entrusted with a mission to investigate and produce plans for correction and/or improvement to be implemented. At a minimum PIP team members would be given resources and guidance on how to develop and process improvements.
The improvement team will report monthly to the QA committee/QAPI committee via a report or in person if requested or additional information was needed.
The facility would take a systematic approach to determine when an in-depth analysis was needed to understand the problem, its causes, and implications of a change.
The facility was to comprehensively assess all involved systems to prevent future events and promote sustained improvements.
Staff were encouraged to use root cause analysis to identify the core of the system breakdown.
The facility would at a minimum report the progress on the established QAPI goals, PIP plans and current data trends to the leadership, staff, and resident and family council.
The team would thoughtfully and thoroughly consider the progress made in the last year toward achieving the QAPI goals and status of sustaining the performance indicators.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
an IP.
maintain systems to gather surveillance data for both residents and staff, compile and analyze the
committee.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
the HUC will make contacts with the employee as needed.3.The infection preventionist should be
certification; however, nothing was provided by the end of the survey period.
245572 01/29/2026
Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of the October 2025, November 2025, infection control (IC) antibiotic stewardship log made no mention that an antibiotic time out had been completed for R4, R3, or R16.
Interview on 1/28/26 at 8:24 a.m., with the infection preventionist identified they were not completing an antibiotic time out for residents who were prescribed antibiotics.
Interview on 1/28/26 at 2:13 p.m., with the administrator and the [NAME] administrator identified they would have expected the infection preventionist to ensure the facility policy is followed and antibiotic time outs were completed.
The facility provided Infection Control-Antibiotic Stewardship policy identified the facility may consider protocols to address improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and an antibiotic review process, also known as Antibiotic Time-Out for all antibiotics prescribed in the facility.
Antibiotic Time Out's prompt clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available. An Antibiotic Time Out can be considered a stop order of an antibiotic when diagnostic test results or symptoms of the resident do not support the diagnosis of infection.
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Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of the facilities infection preventionist job/MDS description identifies the IP must obtain and/or maintain a registered nurse (RN) license by the state of Minnesota and be registered with the Minnesota Board of Nursing.
Must possess leadership skills, have the ability to make sound decisions, and work under pressure.
Must have a thorough knowledge of federal and state guidelines, Medicare, Tardive Dyskinesia Screening, and Case Mix reimbursement or the willingness to obtain training in these areas. A high school diploma or general education development (GED), graduate of an accredited school of nursing, and experience working in a geriatric setting is preferred.
The job description makes no mention that the infection preventionist shall have an IP certification or be enrolled in an IP certification program upon hire.
245572 01/29/2026
Colonial Manor Nursing Home 403 Colonial Avenue Lakefield, MN 56150
Review of the facility provided Vaccination Policy identified the facility would offer all residents vaccinations per the Centers for Disease Control (CDC) recommendations.
The RN Case Manager and Infection control Coordinator would be responsible for researching resident medical records and history to determine if the vaccinations have been given.