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Deficiency Records for El Jen Skilled Care
A list of the most recent deficiencies for El Jen Skilled 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 El Jen Skilled 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-16 | 2024-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-16 | 2024-07-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-18 | 2024-02-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Develop a communication plan. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-31 | 2023-10-19 | 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 | 2023-08-31 | 2023-10-19 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-31 | 2023-10-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-31 | 2023-09-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-31 | 2023-09-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-31 | 2023-09-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-31 | 2023-09-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-31 | 2023-09-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-31 | 2023-09-28 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-08-31 | 2023-09-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-31 | 2023-06-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-07 | 2023-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-07 | 2023-06-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-31 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-31 | 2023-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-31 | 2023-05-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-18 | 2023-03-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-18 | 2023-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-03-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-18 | 2023-03-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-16 | 2022-09-09 | 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 | 2022-06-16 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-16 | 2022-09-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-21 | 2022-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-21 | 2022-07-27 | 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 | 2022-06-21 | 2022-07-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-21 | 2022-07-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-21 | 2022-07-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-21 | 2022-07-27 | 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 | 2022-06-21 | 2022-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-21 | 2022-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-21 | 2022-07-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-21 | 2022-07-27 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-21 | 2022-07-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-27 | 2022-05-17 | Y |
| 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. | Health | 2022-04-27 | 2022-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-27 | 2022-05-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-07 | 2022-02-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-07 | 2022-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-07 | 2022-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-07 | 2022-01-07 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-01 | 2020-01-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-01 | 2020-01-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-01 | 2020-01-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-01 | 2020-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-01 | 2020-01-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-01 | 2020-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-01 | 2020-01-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-11-01 | 2020-01-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-01 | 2019-12-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-01 | 2019-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-01 | 2019-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-01 | 2019-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-01 | 2019-12-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-01 | 2019-12-06 | 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 | 2019-11-01 | 2019-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-01 | 2019-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-01 | 2019-12-06 | N |
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