Deficiency Records for Collar City Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Collar City Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-07 | 2024-01-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-07 | 2024-01-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-07 | 2024-01-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-07 | 2024-01-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-07 | 2024-01-25 | Y |
| 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 | 2023-08-22 | 2023-08-31 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-20 | 2023-06-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-21 | 2023-06-28 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-20 | 2023-06-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-20 | 2023-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-19 | 2023-06-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-20 | 2023-06-19 | 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 | 2023-04-20 | 2023-06-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-06-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-20 | 2023-06-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-06-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-20 | 2023-06-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-20 | 2023-06-19 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-20 | 2023-06-19 | 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 | 2023-04-20 | 2023-06-19 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-04-20 | 2023-06-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-20 | 2023-06-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-20 | 2023-06-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-20 | 2023-06-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-20 | 2023-06-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-15 | 2023-03-31 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-27 | 2021-06-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-27 | 2021-06-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-04-27 | 2021-06-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-27 | 2021-06-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-27 | 2021-06-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-27 | 2021-06-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-27 | 2021-06-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-27 | 2021-06-21 | 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 | 2021-04-27 | 2021-06-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-04-27 | 2021-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-27 | 2021-06-21 | 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 | 2021-04-27 | 2021-06-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-27 | 2021-06-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-27 | 2021-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-27 | 2021-06-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-27 | 2021-06-21 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-21 | 2021-06-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-21 | 2021-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-05-28 | 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 | 2019-09-09 | 2019-11-07 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-09 | 2019-11-07 | 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 | 2019-09-09 | 2019-10-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-09 | 2019-10-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-09 | 2019-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-09 | 2019-10-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-09 | 2019-10-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-09 | 2019-10-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-09-09 | 2019-10-25 | N |
