Deficiency Records for Colonial Health and Rehab Center, LLC
Updated as of October 01, 2019
This is not the most recent data for Colonial Health and Rehab Center, LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-28 | 2019-04-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-28 | 2019-04-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-01-28 | 2019-04-04 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-28 | 2019-03-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-28 | 2019-03-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-28 | 2019-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-28 | 2019-03-13 | Y |
| 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 |
| 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 ne | 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 |
| 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-06-05 | 2018-07-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2017-06-22 | 2017-08-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-22 | 2017-08-15 | 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 | 2017-06-22 | 2017-08-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-22 | 2017-08-15 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-06-22 | 2017-08-15 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-06-22 | 2017-08-15 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-06-22 | 2017-08-15 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-06-22 | 2017-08-15 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-06-16 | 2016-07-25 | 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 | 2016-06-16 | 2016-07-25 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-06-16 | 2016-07-25 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-06-16 | 2016-07-25 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-06-16 | 2016-07-25 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-06-16 | 2016-07-25 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-06-16 | 2016-07-25 | N |
