A list of the most recent deficiencies for Colonial 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-07-28 | 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 | 2023-06-30 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-07-28 | N |
| Post nurse staffing information every day. | Health | 2023-06-30 | 2023-07-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-30 | 2023-07-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-30 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-06-30 | 2023-07-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-30 | 2023-07-28 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-30 | 2023-07-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-30 | 2023-07-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-30 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-21 | 2023-03-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-21 | 2023-03-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-21 | 2023-03-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-21 | 2023-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-03-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-21 | 2023-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-21 | 2023-03-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-21 | 2023-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2023-01-08 | Y |
| Post nurse staffing information every day. | Health | 2022-12-16 | 2023-01-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Have an externally vented heating system. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-06 | 2022-10-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-19 | 2022-09-29 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-19 | 2022-09-29 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-10 | 2022-06-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-10 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-10 | 2022-06-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-10 | 2022-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-10 | 2022-06-02 | 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 | 2022-05-10 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-10 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-10 | 2022-06-02 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-05-10 | 2022-06-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-06-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-10 | 2022-06-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-10 | 2022-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-11-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-29 | 2021-11-26 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-29 | 2021-11-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-06 | 2021-07-16 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-24 | 2021-06-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-06 | 2021-06-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-06 | 2021-06-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-06 | 2021-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-06-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-06 | 2021-06-05 | Y |
