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Deficiency Records for St Luke's Elmore Long Term Care
A list of the most recent deficiencies for St Luke's Elmore Long Term Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for St Luke's Elmore Long Term Care. 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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-23 | 2021-08-10 | N |
| 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. | Health | 2021-07-23 | 2021-08-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-23 | 2021-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-23 | 2021-08-10 | 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 | 2021-07-23 | 2021-08-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-23 | 2021-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-08-10 | 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 | 2021-07-23 | 2021-08-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-23 | 2021-08-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-23 | 2021-08-10 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-07-23 | 2021-08-10 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-07-23 | 2021-08-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-11-23 | 2020-12-10 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2020-11-23 | 2020-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-11-23 | 2020-12-10 | 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 | 2020-01-24 | 2020-02-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-24 | 2020-02-17 | 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 | 2020-01-24 | 2020-02-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-24 | 2020-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-08 | 2019-11-11 | 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 | 2019-10-08 | 2019-10-24 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-10-08 | 2019-10-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-10-08 | 2019-10-16 | N |
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