Deficiency Records for Colonial Health and Rehab Center, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Colonial Health and Rehab Center, LLC. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-02 | 2023-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-23 | 2022-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-06-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-08 | 2021-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-08 | 2021-11-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-08 | 2021-11-04 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-08 | 2021-11-04 | 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 | 2021-07-08 | 2021-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-08 | 2021-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-08 | 2021-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-08 | 2021-10-01 | N |
| Provide or obtain dental services for each resident. | Health | 2021-07-08 | 2021-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-08 | 2021-10-01 | 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 | 2021-07-08 | 2021-10-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-08 | 2021-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-08 | 2021-10-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-08 | 2021-10-01 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-07-08 | 2021-08-09 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-08 | 2021-08-09 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-15 | 2021-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-15 | 2021-08-02 | 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 | 2019-11-14 | 2019-12-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-14 | 2019-12-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-14 | 2019-12-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-14 | 2019-12-27 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-11-14 | 2019-12-27 | 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 | 2019-11-14 | 2019-12-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-14 | 2019-12-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-14 | 2019-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-14 | 2019-12-27 | 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 | 2019-11-14 | 2019-12-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-14 | 2019-12-27 | N |
| Provide appropriate foot care. | Health | 2019-11-14 | 2019-12-27 | 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 | 2019-11-14 | 2019-12-27 | 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 | 2019-11-14 | 2019-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-14 | 2019-12-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-14 | 2019-12-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-14 | 2019-12-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-05 | 2018-07-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-06-05 | 2018-07-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-06-05 | 2018-07-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-05 | 2018-07-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-05 | 2018-07-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-05 | 2018-07-17 | 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 | 2018-06-05 | 2018-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-05 | 2018-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-05 | 2018-07-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-05 | 2018-07-17 | 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 | 2018-06-05 | 2018-07-17 | 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 | 2018-06-05 | 2018-07-17 | 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 | 2018-06-05 | 2018-07-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-06-05 | 2018-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-05 | 2018-07-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-06-05 | 2018-07-17 | N |
