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Deficiency Records for Elmwood Manor Nursing Home
A list of the most recent deficiencies for Elmwood 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 Elmwood 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-27 | 2023-03-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-27 | 2023-03-24 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-09-30 | 2022-11-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-30 | 2022-11-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-30 | 2022-11-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-09-30 | 2022-11-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-30 | 2022-11-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-30 | 2022-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-30 | 2022-11-14 | 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 | 2022-09-30 | 2022-11-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-30 | 2022-11-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-30 | 2022-11-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-30 | 2022-11-14 | 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 | 2022-09-30 | 2022-11-14 | 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 | 2022-09-30 | 2022-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-30 | 2022-11-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-30 | 2022-11-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-09-30 | 2022-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-11-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-30 | 2022-11-14 | N |
| 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. | Health | 2022-09-30 | 2022-11-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-30 | 2022-11-14 | Y |
| 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 | 2022-09-28 | 2022-11-14 | 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 | 2022-09-28 | 2022-11-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-28 | 2022-11-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-28 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-11 | 2019-10-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-12 | 2019-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-11 | 2019-10-07 | N |
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