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Deficiency Records for Colonial Terrace Care Center
A list of the most recent deficiencies for Colonial Terrace 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 Terrace 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-21 | 2024-08-27 | 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 | 2024-06-21 | 2024-08-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-21 | 2024-08-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-21 | 2024-08-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-21 | 2024-08-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-21 | 2024-08-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-07-08 | 2024-08-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-08 | 2024-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-11 | 2024-05-31 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-03 | 2023-08-10 | 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 | 2023-08-03 | 2023-08-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-03 | 2023-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-03 | 2023-08-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-03 | 2023-08-10 | 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 | 2023-05-17 | 2023-06-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-17 | 2023-06-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-17 | 2023-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-17 | 2023-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-17 | 2023-06-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-17 | 2023-06-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-17 | 2023-06-26 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-05-17 | 2023-06-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-17 | 2023-06-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-15 | 2022-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-15 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-15 | 2022-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-28 | 2019-12-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-28 | 2019-12-09 | 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 | 2019-10-28 | 2019-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2019-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-28 | 2019-12-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-17 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-17 | 2019-11-20 | N |
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