Deficiency Records for Colonial Heights Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Colonial Heights 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-12 | 2023-06-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-12 | 2023-06-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-12 | 2023-06-20 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-05-12 | 2023-06-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-06 | 2023-05-10 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-06 | 2023-05-10 | Y |
| Report COVID19 data to residents and families. | Health | 2023-04-06 | 2023-05-10 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-06 | 2023-05-10 | Y |
| 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 | 2022-10-28 | 2022-12-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-28 | 2022-12-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-28 | 2022-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-28 | 2022-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-28 | 2022-12-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-28 | 2022-12-08 | 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 | 2022-10-28 | 2022-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-12-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-28 | 2022-12-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-28 | 2022-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-28 | 2022-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2022-12-08 | Y |
| 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 | 2022-10-28 | 2022-12-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-28 | 2022-12-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-28 | 2022-12-08 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-01 | 2022-11-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-11-01 | 2022-11-18 | N |
| Meet other general requirements. | Fire Safety | 2022-11-01 | 2022-11-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-29 | 2022-07-29 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-29 | 2022-07-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-29 | 2022-07-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-29 | 2022-07-29 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-29 | 2022-07-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-29 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-04-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-25 | 2022-04-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-25 | 2022-04-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-25 | 2022-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-17 | 2021-12-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-17 | 2021-12-29 | 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 | 2021-11-17 | 2021-12-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-17 | 2021-12-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-17 | 2021-12-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-17 | 2021-12-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-17 | 2021-12-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-17 | 2021-12-29 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-11-17 | 2021-12-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-17 | 2021-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-17 | 2021-12-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-17 | 2021-12-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-14 | 2019-05-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-25 | 2019-04-25 | 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 | 2019-02-25 | 2019-04-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-25 | 2019-04-25 | 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 | 2019-02-25 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-25 | 2019-04-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-25 | 2019-04-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-02-25 | 2019-04-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-25 | 2019-04-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-25 | 2019-04-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-25 | 2019-04-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-25 | 2019-04-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-25 | 2019-04-02 | 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 | 2019-02-25 | 2019-04-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-25 | 2019-04-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-25 | 2019-04-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-25 | 2019-04-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-25 | 2019-04-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-25 | 2019-04-02 | N |
| 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 | 2019-02-25 | 2019-04-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-25 | 2019-04-02 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-02-25 | 2019-04-02 | N |
| Keep all essential equipment working safely. | Health | 2019-02-25 | 2019-04-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2017-12-18 | 2018-02-21 | 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 | 2017-12-18 | 2018-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-18 | 2018-02-21 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-11-09 | 2017-12-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-11-09 | 2017-12-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-09 | 2017-12-15 | 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 | 2017-11-09 | 2017-12-15 | N |
| Hire sufficient dietary support personnel. | Health | 2017-11-09 | 2017-12-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-09 | 2017-12-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-09 | 2017-12-15 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-11-09 | 2017-08-03 | N |
