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Deficiency Records for Colonial Gardens Nursing Home
A list of the most recent deficiencies for Colonial Gardens 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 Colonial Gardens 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-08-21 | 2024-09-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-21 | 2024-09-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-21 | 2024-09-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-21 | 2024-09-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-05 | 2024-08-16 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-27 | 2024-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-27 | 2024-07-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-27 | 2024-07-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-27 | 2024-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-27 | 2024-07-26 | 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 | 2024-06-27 | 2024-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-27 | 2024-07-26 | 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 | 2024-06-27 | 2024-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-27 | 2024-07-26 | 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 | 2024-06-27 | 2024-07-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-06-27 | 2024-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-27 | 2024-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-27 | 2024-07-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-06-27 | 2024-07-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-27 | 2024-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-27 | 2024-07-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-27 | 2024-07-26 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-06-27 | 2024-07-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-06-27 | 2024-07-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-27 | 2024-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-09-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-21 | 2023-07-07 | 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 | 2023-05-02 | 2023-05-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-23 | 2023-04-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-04-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-10 | 2023-04-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-04-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-24 | 2023-04-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-24 | 2023-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-04-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-02-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-10 | 2023-01-20 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-01-10 | 2023-01-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2022-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-08 | 2022-05-20 | 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 | 2022-04-08 | 2022-05-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-08 | 2022-05-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-08 | 2022-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-08 | 2022-05-20 | N |
| 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 | 2022-04-08 | 2022-05-20 | N |
| Post nurse staffing information every day. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-08 | 2022-05-20 | 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 | 2022-04-08 | 2022-05-20 | 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 | 2022-04-08 | 2022-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-05-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-08 | 2022-05-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-20 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-04-08 | 2022-05-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-04-08 | 2022-05-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-08 | 2022-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-08 | 2022-05-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-08 | 2022-05-20 | 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 | 2022-04-08 | 2022-05-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-16 | 2022-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-16 | 2022-05-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-16 | 2022-05-10 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-06 | 2022-04-28 | 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 | 2022-04-06 | 2022-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-06 | 2022-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-06 | 2022-04-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-06 | 2022-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-06 | 2022-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-06 | 2022-04-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-06 | 2022-04-28 | 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 | 2019-11-22 | 2020-01-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-22 | 2020-01-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-22 | 2020-01-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-22 | 2020-01-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-22 | 2020-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-22 | 2020-01-03 | 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 | 2019-11-22 | 2020-01-03 | 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 | 2019-11-22 | 2020-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-11-22 | 2020-01-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-22 | 2020-01-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-22 | 2020-01-03 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-22 | 2020-01-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-25 | 2020-01-03 | N |
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