Deficiency Records for Colony Center For Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Colony Center For Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-18 | 2024-03-07 | 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 | 2024-01-18 | 2024-02-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-18 | 2024-01-24 | 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 | 2024-01-18 | 2024-01-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-18 | 2024-01-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-01-18 | 2024-01-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-18 | 2024-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-18 | 2024-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-18 | 2024-01-24 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-01-18 | 2024-01-24 | N |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2024-01-18 | 2024-01-24 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-01-18 | 2024-01-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-01-18 | 2024-01-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-18 | 2024-01-24 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-01-18 | 2024-01-24 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-01-18 | 2024-01-24 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-01-18 | 2024-01-24 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-01-18 | 2024-01-24 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide training in compliance and ethics. | Health | 2024-01-18 | 2024-01-24 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-01-18 | 2024-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-07 | 2022-01-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-07 | 2022-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2022-01-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-07 | 2022-01-14 | 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 | 2021-12-07 | 2022-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-07 | 2022-01-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-03 | 2019-08-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-03 | 2019-08-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-03 | 2019-08-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-03 | 2019-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-03 | 2019-08-17 | N |
