CALEDONIA REHABILITATION & RETIREMENT CENTER
Inspection History Overview
Health Violations by Year
2023 4 violations
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Submit a timely, acceptable plan for facility closure, including notification of the appropriate entities and ensuring residents are transferred in a safe and orderly manner.
2022 18 violations
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Honor the resident's right to manage his or her financial affairs.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Ensure each resident receives an accurate assessment.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide safe, appropriate pain management for a resident who requires such services.
Post nurse staffing information every day.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Ensure staff are vaccinated for COVID-19
2021 22 violations
Honor the resident's right to manage his or her financial affairs.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Honor the resident's right to manage his or her financial affairs.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Ensure medication error rates are not 5 percent or greater.
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.
2020 19 violations
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure that residents are free from significant medication errors.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Observe each nurse aide's job performance and give regular training.
Post nurse staffing information every day.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
2019 25 violations
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Ensure that residents are free from significant medication errors.
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
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.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Employ staff that are licensed, certified, or registered in accordance with state laws.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2018 4 violations
Ensure each resident receives an accurate assessment.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
2017 7 violations
Provide housekeeping and maintenance services.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care by qualified persons according to each resident's written plan of care.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Develop policies and procedures for influenza and pneumococcal immunizations.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2023 1 penalties totaling $13,636
2022 6 penalties totaling $77,460
2021 3 penalties totaling $22,600
2020 9 penalties totaling $67,888
2019 1 penalties totaling $0
Fire Safety Deficiencies
No description available
Inspection Survey Reports
No survey data available for this facility.