CMS Inspection Results for COLONY OAKS CARE CTR

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 02/27/2009 Fire Safety Survey for COLONY OAKS CARE CTR

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
signs that state that exit doors are to be kept closed.	Widespread	Minimal harm or potential for actual harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm

 

• 02/24/2009 Health Survey for COLONY OAKS CARE CTR

Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Widespread	Immediate jeopardy to resident health or safety
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm

 

• 03/13/2008 Health Survey for COLONY OAKS CARE CTR

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 03/11/2008 Fire Safety Survey for COLONY OAKS CARE CTR

Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm

 

• 03/26/2007 Health Survey for COLONY OAKS CARE CTR

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm

 

• 03/26/2007 Fire Safety Survey for COLONY OAKS CARE CTR

Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm