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Deficiency Records for Elizabeth Church Manor Nursing Home
A list of the most recent deficiencies for Elizabeth Church Manor Nursing Home. 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 Elizabeth Church Manor Nursing Home. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-22 | 2024-10-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-22 | 2024-10-21 | 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 | 2024-08-22 | 2024-10-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-22 | 2024-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-22 | 2024-10-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-22 | 2024-10-21 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-27 | 2024-10-21 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-10 | 2024-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-10 | 2024-05-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-01 | 2022-10-28 | N |
| Post nurse staffing information every day. | Health | 2022-09-01 | 2022-10-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-01 | 2022-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-01 | 2022-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-01 | 2022-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-16 | 2020-03-10 | 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 | 2020-01-16 | 2020-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-16 | 2020-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-16 | 2020-03-10 | 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 | 2020-01-16 | 2020-03-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-16 | 2020-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-01-14 | 2020-02-28 | N |
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