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Inspection visit

Health inspection

COLONY CENTER FOR HEALTH AND REHABILITATIONCMS #22543527 citations on this visit
27 citations recorded

Citations

27 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0582GeneralS&S Bno actual harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0623GeneralS&S Bno actual harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625GeneralS&S Bno actual harm

    F625 - Transfer and discharge-

    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.

  • 0636GeneralS&S Bno actual harm

    F636 - Resident Assessment

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • 0638GeneralS&S Bno actual harm

    F638 - Quarterly Review Assessment

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0641GeneralS&S Bno actual harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0694GeneralS&S Dpotential for harm

    F694 - Parenteral Fluids

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  • 0697SeriousS&S Gactual harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0712GeneralS&S Epotential for harm

    F712 - Frequency of physician visits

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  • 0758GeneralS&S Epotential for harm

    F758 - Medication Errors

    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.

  • 0825GeneralS&S Dpotential for harm

    F825 - Specialized rehabilitative services

    Provide or get specialized rehabilitative services as required for a resident.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0844GeneralS&S Cno actual harm

    F844 - Disclosure of ownership

    Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

  • 0847GeneralS&S Epotential for harm

    F847 - Entering Into Binding Arbitration Agreements

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

  • 0848GeneralS&S Bno actual harm

    F848 - Arbitrator/Venue Selection and Retention of Agreements

    Provide a neutral and fair arbitration process and agree to arbitrator and venue.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0925GeneralS&S Epotential for harm

    F925 - Maintain an effective pest control program so that the facility is free of

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0940GeneralS&S Epotential for harm

    F940 - Training Requirements

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  • 0941GeneralS&S Fpotential for harm

    F941 - Training Requirements

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  • 0942GeneralS&S Epotential for harm

    F942 - Training Requirements

    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  • 0943GeneralS&S Epotential for harm

    F943 - Abuse, neglect, and exploitation

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  • 0944GeneralS&S Fpotential for harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0946GeneralS&S Fpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Epotential for harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

FAQ · About this visit

Common questions about this visit

What happened during the January 18, 2024 survey of COLONY CENTER FOR HEALTH AND REHABILITATION?

This was a inspection survey of COLONY CENTER FOR HEALTH AND REHABILITATION on January 18, 2024. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at COLONY CENTER FOR HEALTH AND REHABILITATION on January 18, 2024?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.