A list of the most recent deficiencies for Colonial Terrace Care 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 emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-03 | 2023-08-10 | 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 | 2023-08-03 | 2023-08-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-03 | 2023-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-03 | 2023-08-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-03 | 2023-08-10 | 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 | 2023-05-17 | 2023-06-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-17 | 2023-06-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-17 | 2023-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-17 | 2023-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-05-17 | 2023-06-26 | 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 | 2023-05-17 | 2023-06-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-17 | 2023-06-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-17 | 2023-06-26 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-05-17 | 2023-06-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-17 | 2023-06-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-15 | 2022-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-15 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-15 | 2022-07-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-08 | 2021-07-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-08 | 2021-07-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-08 | 2021-07-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-08 | 2021-07-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-08 | 2021-07-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-08 | 2021-07-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-08 | 2021-07-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-06-08 | 2021-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-08 | 2021-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-28 | 2019-12-09 | 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 | 2019-10-28 | 2019-12-09 | 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 | 2019-10-28 | 2019-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2019-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-28 | 2019-12-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-17 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-17 | 2019-11-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-07-12 | 2018-08-30 | 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 | 2018-07-12 | 2018-08-30 | 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 | 2018-07-12 | 2018-08-30 | 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 | 2018-07-12 | 2018-08-30 | 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 | 2018-07-12 | 2018-08-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-07-12 | 2018-08-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-03 | 2018-08-30 | N |
| Have an externally vented heating system. | Fire Safety | 2018-07-03 | 2018-07-19 | 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 | 2018-07-03 | 2018-07-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-07-03 | 2018-07-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-03 | Not Fixed | N |
