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Deficiency Records for Shawnee Colonial Estates Nursing Home
A list of the most recent deficiencies for Shawnee Colonial Estates Nursing Home. 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 Shawnee Colonial Estates Nursing Home. 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? |
|---|---|---|---|---|
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-11-21 | 2022-01-19 | 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 | 2021-11-21 | 2022-01-19 | 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 | 2021-11-21 | 2022-01-19 | 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 | 2021-11-21 | 2022-01-19 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2021-11-21 | 2022-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-21 | 2022-01-19 | 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 | 2021-11-21 | 2022-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-21 | 2022-01-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-21 | 2022-01-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-21 | 2022-01-19 | Y |
| 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 | 2021-11-17 | 2022-01-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-17 | 2022-01-19 | 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 | 2021-11-17 | 2022-01-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-17 | 2022-01-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-17 | 2022-01-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-17 | 2022-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-17 | 2022-01-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-12 | 2019-10-28 | 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 | 2019-09-12 | 2019-10-28 | 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 | 2019-09-12 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-12 | 2019-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-12 | 2019-10-18 | 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 | 2018-07-12 | 2018-08-27 | 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 | 2018-07-12 | 2018-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-12 | 2018-08-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-12 | 2018-08-27 | 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 | 2018-07-12 | 2018-08-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-12 | 2018-08-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-12 | 2018-08-27 | 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 | 2018-07-12 | 2018-08-27 | 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 | 2018-07-12 | 2018-08-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-07-12 | 2018-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-12 | 2018-08-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-12 | 2018-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-11 | 2018-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-11 | 2018-07-19 | N |
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