A list of the most recent deficiencies for Colby Operator, 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-14 | 2023-12-15 | 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 | 2023-11-14 | 2023-12-15 | 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 | 2023-11-14 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-14 | 2023-12-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-28 | 2023-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-03 | 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 | 2023-09-28 | 2023-11-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-28 | 2023-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-11-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-28 | 2023-11-03 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-28 | 2023-11-03 | N |
| Post nurse staffing information every day. | Health | 2023-09-28 | 2023-11-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-28 | 2023-11-03 | 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 | 2023-09-28 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-03 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-28 | 2023-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-11-03 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-28 | 2023-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2022-11-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-22 | 2022-09-23 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Develop a communication plan. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-08 | 2022-06-17 | 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 | 2022-06-08 | 2022-06-17 | 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 | 2022-06-08 | 2022-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-06-08 | 2022-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-08 | 2022-06-17 | 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 | 2022-05-12 | 2022-06-13 | 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 | 2022-05-12 | 2022-06-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-12 | 2022-06-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-12 | 2022-06-13 | 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 | 2022-05-12 | 2022-06-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-24 | 2022-04-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-24 | 2022-04-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-24 | 2022-04-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-05 | 2020-11-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-10-05 | 2020-11-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-05 | 2020-11-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-05 | 2020-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-05 | 2020-11-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-10-05 | 2020-11-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-05 | 2020-11-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-11 | 2020-03-31 | 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 | 2020-03-11 | 2020-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
