A list of the most recent deficiencies for Colonial Haven. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-13 | 2024-04-13 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2024-02-13 | 2024-03-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-13 | 2024-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-13 | 2024-03-13 | 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 | 2024-02-08 | 2024-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | 2024-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-25 | 2023-02-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-25 | 2023-02-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-25 | 2023-02-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-25 | 2023-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-25 | 2023-02-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-25 | 2023-02-24 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-24 | 2023-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-24 | 2023-02-17 | 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 | 2022-08-11 | 2022-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-11 | 2022-09-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-09 | 2022-06-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-09 | 2022-06-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-09 | 2022-06-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-28 | 2021-10-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-28 | 2021-10-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-28 | 2021-10-13 | 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 | 2021-09-28 | 2021-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-28 | 2021-10-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-28 | 2021-10-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-28 | 2021-10-13 | 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 | 2021-09-28 | 2021-10-13 | 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 | 2021-09-23 | 2021-10-11 | N |
