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Deficiency Records for Colonial Village
A list of the most recent deficiencies for Colonial Village. 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 Village. 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 enclosure around a vertical opening shaft. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-10 | 2023-07-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-08 | 2023-06-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-08 | 2023-06-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-06-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-08 | 2023-06-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-06-30 | Y |
| 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 | 2023-06-08 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-30 | Y |
| 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 | 2023-06-08 | 2023-06-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-06-30 | Y |
| 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 necessary and PRN use is limited. | Health | 2023-06-08 | 2023-06-30 | Y |
| 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 | 2023-06-08 | 2023-06-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-06-30 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-06-08 | 2023-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-19 | 2022-10-11 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-12-09 | 2022-01-07 | 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 | 2021-12-09 | 2022-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-09 | 2022-01-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-02 | 2021-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-11-30 | 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 | 2021-11-02 | 2021-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-11-30 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-02-05 | 2020-02-20 | 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 | 2020-02-05 | 2020-02-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-04 | 2019-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-04 | 2019-12-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-04 | 2019-12-31 | N |
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