A list of the most recent deficiencies for Colonial Acres Nursing Home. 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? |
|---|---|---|---|---|
| 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 | 2023-11-15 | 2024-01-15 | 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 | 2023-11-15 | 2024-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-15 | 2024-01-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-16 | 2023-12-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-16 | 2023-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-17 | 2022-12-22 | 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 | 2022-11-17 | 2022-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-22 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-11-17 | 2022-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-17 | 2022-12-13 | 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 | 2022-11-17 | 2022-12-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-17 | 2022-12-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-06 | 2021-05-28 | 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 | 2021-05-06 | 2021-05-28 | 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 | 2021-05-06 | 2021-05-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-06 | 2021-05-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-06 | 2021-05-28 | 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 | 2021-05-06 | 2021-05-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-05-06 | 2021-05-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-06 | 2021-05-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-06 | 2021-05-28 | N |
