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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?
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-10-24 2024-11-22 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 2024-10-24 2024-11-22 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 2024-10-24 2024-11-22 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 2024-10-24 2024-11-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-10-24 2024-11-22 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 2024-10-24 2024-11-22 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-10-24 2024-11-22 Y
Have an alternate power supply for its alarm system. Fire Safety 2024-10-25 2024-11-22 N
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

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