Deficiency Records for Colonial Skilled Nursing Facility LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Colonial Skilled Nursing Facility LLC. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-01 | 2024-03-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-02-01 | 2024-03-01 | 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 | 2024-02-01 | 2024-03-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-01 | 2024-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-03-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-02-01 | 2024-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-31 | 2024-03-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-06 | 2022-10-27 | 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 | 2022-10-06 | 2022-10-27 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-06 | 2022-10-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-06 | 2022-10-27 | 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 | 2022-10-06 | 2022-10-27 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-06 | 2022-10-27 | 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 | 2022-10-04 | 2022-10-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-04 | 2022-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2022-10-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-04 | 2022-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-10-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-12 | 2021-09-10 | 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 | 2021-08-12 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-12 | 2021-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-12 | 2021-09-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-10 | 2021-09-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-10 | 2021-09-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-01 | Y |
