Deficiency Records for Colonial Vista Post-Acute and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Colonial Vista Post-Acute and Rehab 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-09-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-02 | 2023-09-11 | 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 | 2023-08-08 | 2023-08-30 | 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 | 2023-08-08 | 2023-08-30 | 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 | 2023-08-08 | 2023-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-08 | 2023-08-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-08-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-02 | 2023-08-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-02 | 2023-08-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-02 | 2023-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-08-15 | N |
| Meet other general requirements. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-02 | 2023-08-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-02 | 2023-08-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-26 | 2022-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-26 | 2022-06-30 | 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 | 2022-05-26 | 2022-06-30 | 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 | 2022-05-26 | 2022-06-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-26 | 2022-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-06-30 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-05-26 | 2022-06-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-26 | 2022-06-30 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-05-26 | 2022-06-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Develop a communication plan. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-11 | 2022-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-28 | 2019-09-19 | 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 | 2019-06-28 | 2019-09-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-28 | 2019-09-19 | 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 | 2019-06-28 | 2019-09-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-28 | 2019-09-19 | 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 | 2019-06-28 | 2019-09-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-28 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-28 | 2019-09-19 | 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 | 2019-06-28 | 2019-09-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-28 | 2019-09-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-28 | 2019-09-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-28 | 2019-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-28 | 2019-09-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-20 | 2019-07-22 | N |
