Deficiency Records for Colonial Park Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Colonial Park Rehabilitation and Nursing Center. 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-03 | 2022-08-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-11 | 2022-08-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-11 | 2022-08-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-11 | 2022-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-07-25 | 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 | 2022-06-03 | 2022-07-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-03 | 2022-07-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-03 | 2022-07-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-03 | 2022-07-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-03 | 2022-07-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-03 | 2022-07-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-03 | 2022-07-25 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-03 | 2022-07-25 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-03 | 2022-07-25 | 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 | 2022-06-03 | 2022-07-25 | 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 | 2022-06-03 | 2022-07-25 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-06-03 | 2022-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-13 | 2022-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-02-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-13 | 2022-02-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-30 | 2019-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-30 | 2019-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-30 | 2019-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-30 | 2019-10-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-08-30 | 2019-10-21 | 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 | 2019-08-30 | 2019-10-21 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-08-30 | 2019-10-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-29 | 2019-08-30 | 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 | 2019-08-29 | 2019-08-30 | 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 | 2018-05-11 | 2018-07-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-11 | 2018-07-09 | 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 | 2018-05-11 | 2018-07-09 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-05-11 | 2018-07-09 | 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 | 2018-05-10 | 2018-07-09 | 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 | 2018-05-10 | 2018-07-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-10 | 2018-07-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-05-10 | 2018-07-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-05-10 | 2018-07-09 | N |
