Deficiency Records for Colonial Health and Rehab Center, LLC

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Updated as of March 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