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Deficiency Records for Columbia Manor Health and Rehabilitation
A list of the most recent deficiencies for Columbia Manor Health and Rehabilitation. 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 Columbia Manor Health and Rehabilitation. 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? |
|---|---|---|---|---|
| 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 | 2024-05-31 | 2024-07-12 | 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 | 2024-05-31 | 2024-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-31 | 2024-07-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-31 | 2024-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-07-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-31 | 2024-07-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-05-31 | 2024-07-12 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-05-31 | 2024-07-12 | N |
| 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 | 2024-05-31 | 2024-07-12 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-05-31 | 2024-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-31 | 2024-07-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-31 | 2024-07-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-31 | 2024-07-12 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-28 | 2023-10-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-28 | 2023-10-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-12 | 2023-06-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-12 | 2023-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-06-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-12 | 2023-06-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-13 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-02 | 2022-06-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-11 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-07-15 | 2021-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-11 | N |
| Post nurse staffing information every day. | Health | 2021-07-15 | 2021-08-11 | 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 | 2021-07-15 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
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