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Deficiency Records for Colonial Village
View the most recent health deficiencies and inspection results for Colonial Village. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Colonial Village. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-31 | 2025-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-31 | 2025-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-31 | 2025-01-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-31 | 2025-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-31 | 2025-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-31 | 2025-01-06 | 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 | 2024-10-31 | 2025-01-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-31 | 2024-11-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-10-31 | 2024-11-21 | 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 | 2024-10-31 | 2024-11-21 | 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 | 2024-10-31 | 2024-11-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-10-31 | 2024-11-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-10-31 | 2024-11-21 | 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 | 2024-10-31 | 2024-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-31 | 2024-11-21 | 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 | 2024-10-31 | 2024-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-31 | 2024-11-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-08 | 2023-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-30 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-08 | 2023-06-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-06-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-08 | 2023-06-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-06-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-08 | 2023-06-30 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-08 | 2023-06-30 | 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 | 2023-06-08 | 2023-06-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-06-30 | 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 | 2023-06-08 | 2023-06-30 | Y |
| 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 | 2023-06-08 | 2023-06-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-06-30 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-06-08 | 2023-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-06-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-11-02 | 2022-01-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-02 | 2021-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-11-30 | 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 | 2021-11-02 | 2021-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-11-30 | N |