Deficiency Records for Columbus Colony Elderly Care
Updated as of June 01, 2021
This is not the most recent data for Columbus Colony Elderly Care. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-08-05 | 2020-08-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-06-06 | 2020-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-06-06 | 2020-08-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-04 | 2020-03-13 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-12-26 | 2020-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-26 | 2020-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-20 | 2019-12-06 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-11-01 | 2019-11-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-23 | 2019-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-01 | 2019-08-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-01 | 2019-08-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-01 | 2019-08-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-01 | 2019-08-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-01 | 2019-08-23 | Y |
| 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 | 2019-06-21 | 2019-08-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-06-21 | 2019-08-23 | Y |
| 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 other general requirements that are deficient. | 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 |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-27 | 2019-05-22 | 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 |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-28 | 2019-05-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-11 | 2019-01-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-01 | 2018-11-12 | Y |
| 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 | 2018-08-28 | 2018-09-14 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-08-28 | 2018-09-14 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-08-28 | 2018-09-14 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-08-28 | 2018-09-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-28 | 2018-09-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-21 | 2018-06-22 | Y |
| 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 other general requirements that are deficient. | 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-02 | 2017-08-14 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-02 | 2017-08-14 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-02 | 2017-08-14 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-02 | 2017-08-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-02 | 2017-08-14 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-02 | 2017-08-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-02-28 | 2017-08-03 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-03-02 | 2017-08-03 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-02 | 2017-08-03 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-02 | 2017-08-03 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-03-02 | 2017-08-03 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-03-02 | 2017-08-03 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-03-02 | 2017-08-03 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-02 | 2017-08-03 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-02 | 2017-08-03 | N |
