A list of the most recent deficiencies for College Street Health Care 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? |
|---|---|---|---|---|
| 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 | 2023-06-14 | 2023-07-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-14 | 2023-07-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-14 | 2023-07-05 | 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 | 2023-06-14 | 2023-07-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-14 | 2023-07-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-14 | 2023-07-05 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-06-14 | 2023-07-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-14 | 2023-07-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-14 | 2023-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-04-18 | 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 | 2022-05-11 | 2022-06-07 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-05-11 | 2022-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-11 | 2022-06-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-11 | 2022-05-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-11 | 2022-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-11 | 2022-05-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-11 | 2022-05-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-28 | 2021-06-24 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-04 | 2020-03-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-04 | 2020-03-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-04 | 2020-03-13 | 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 | 2020-02-04 | 2020-03-13 | N |
| Provide or obtain dental services for each resident. | Health | 2020-02-04 | 2020-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-04 | 2020-03-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-04 | 2020-03-13 | 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 | 2020-02-04 | 2020-03-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-04 | 2020-03-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-04 | 2020-03-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-04 | 2020-03-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-04 | 2020-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-04 | 2020-03-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-11 | Not Fixed | N |
