A list of the most recent deficiencies for Columbus Colony Elderly Care. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-23 | 2023-02-17 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-01-23 | 2023-02-17 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-01-23 | 2023-02-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-14 | 2022-09-30 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-01-26 | 2022-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-31 | 2022-04-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-31 | 2022-04-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-01-31 | 2022-04-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-31 | 2022-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-31 | 2022-04-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-31 | 2022-04-04 | N |
| 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 | 2022-01-31 | 2022-04-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-31 | 2022-04-04 | 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 | 2022-01-31 | 2022-04-04 | 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 | 2022-01-31 | 2022-04-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-31 | 2022-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-31 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-31 | 2022-04-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-31 | 2022-04-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-31 | 2022-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-24 | 2022-04-04 | 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 | 2022-02-24 | 2022-04-04 | Y |
| Meet other general requirements. | Fire Safety | 2022-01-26 | 2022-04-04 | 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 | 2022-01-26 | 2022-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-26 | 2022-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-16 | 2021-08-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-25 | 2019-05-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-04-25 | 2019-05-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-25 | 2019-05-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-25 | 2019-05-22 | 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 | 2019-04-25 | 2019-05-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-25 | 2019-05-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-25 | 2019-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-25 | 2019-05-22 | N |
| 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 | 2019-04-25 | 2019-05-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-25 | 2019-05-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-25 | 2019-05-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-25 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-25 | 2019-05-22 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-25 | 2019-05-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-04-25 | 2019-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-25 | 2019-05-22 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Develop a communication plan. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-29 | 2019-05-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-04-19 | 2018-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2018-04-19 | 2018-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-19 | 2018-06-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-19 | 2018-06-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-19 | 2018-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-19 | 2018-06-01 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-17 | 2018-06-01 | N |
