Deficiency Records for Columbia Manor Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Columbia Manor 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-28 | 2023-10-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-28 | 2023-10-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-12 | 2023-06-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-12 | 2023-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-06-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-12 | 2023-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-12 | 2023-06-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-13 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-02 | 2022-06-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-11 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-07-15 | 2021-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-11 | N |
| Post nurse staffing information every day. | Health | 2021-07-15 | 2021-08-11 | 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 | 2021-07-15 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-15 | 2021-08-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-16 | 2021-06-14 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-08-15 | 2019-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-15 | 2019-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-15 | 2019-09-20 | N |