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Deficiency Records for The Elms
A list of the most recent deficiencies for The Elms. 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 The Elms. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-02 | 2024-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-02 | 2024-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-25 | 2024-05-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-25 | 2024-05-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-02 | 2024-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-25 | 2024-05-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-02 | 2024-05-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-02 | 2024-05-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-05-02 | 2024-05-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-25 | 2024-05-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-25 | 2024-05-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-25 | 2024-05-10 | N |
| 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. | Health | 2024-04-25 | 2024-05-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-25 | 2024-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-02 | 2024-05-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-02 | 2024-05-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-02 | 2024-05-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-25 | 2024-02-15 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-03-13 | N |
| 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. | Health | 2023-02-24 | 2023-03-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-07 | 2022-12-22 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-01-06 | 2022-01-30 | N |
| 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. | Health | 2022-01-06 | 2022-01-30 | N |
| 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. | Health | 2022-01-06 | 2022-01-30 | N |
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