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Deficiency Records for Colonial Care Center
A list of the most recent deficiencies for Colonial Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Colonial Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-06-04 | 2024-06-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-04 | 2024-06-21 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-04-05 | 2024-04-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-23 | 2024-04-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-23 | 2024-03-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-23 | 2024-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-03-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-23 | 2024-03-22 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-23 | 2024-03-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-22 | N |
| 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. | Health | 2024-02-23 | 2024-03-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-23 | 2024-03-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-23 | 2024-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-22 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-23 | 2024-03-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-23 | 2024-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-27 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-25 | 2023-11-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-09-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-31 | 2023-06-21 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-29 | 2023-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-13 | 2023-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-03-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-13 | 2023-03-21 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-13 | 2023-03-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-03 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-08-05 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-19 | 2022-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-31 | 2022-06-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-06-08 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-18 | 2022-05-13 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-31 | 2022-04-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-18 | 2022-03-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-18 | 2022-03-18 | N |
| 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. | Health | 2022-02-18 | 2022-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-18 | 2022-03-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-18 | 2022-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-18 | 2022-03-18 | N |
| 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. | Health | 2022-02-18 | 2022-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-18 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2022-02-18 | 2022-03-18 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2022-02-18 | 2022-03-18 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-18 | 2022-03-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-02-18 | 2022-03-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2021-11-05 | 2021-11-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-05 | 2021-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-26 | 2021-11-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-29 | 2020-02-27 | N |
| 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. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-29 | 2020-02-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-29 | 2020-02-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-29 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-29 | 2020-02-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-29 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-29 | 2020-02-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-29 | 2020-02-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-29 | 2020-02-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-29 | 2020-02-27 | N |
| 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. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-29 | 2020-02-27 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-01-29 | 2020-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-29 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-29 | 2020-02-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-28 | 2020-02-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-28 | 2020-02-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-28 | 2020-02-18 | N |
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