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Deficiency Records for Ellen Memorial Health Care Center

A list of the most recent deficiencies for Ellen Memorial Health Care Center. 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 Ellen Memorial Health Care Center. 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?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-15 2024-05-14 N
Respond appropriately to all alleged violations. Health 2024-03-15 2024-05-14 N
Provide activities to meet all resident's needs. Health 2024-03-15 2024-05-14 N
Provide enough food/fluids to maintain a resident's health. Health 2024-03-15 2024-05-14 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2024-03-15 2024-05-14 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2024-03-15 2024-05-14 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 2024-03-27 2024-04-23 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-03-27 2024-04-23 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-03-27 2024-04-23 N
Provide and implement an infection prevention and control program. Health 2023-10-05 2023-10-31 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-29 2023-10-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-16 2023-04-13 Y
Respond appropriately to all alleged violations. Health 2023-02-16 2023-04-13 Y
Provide and implement an infection prevention and control program. Health 2023-02-16 2023-04-13 Y
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 2023-03-17 2023-04-13 N
Ensure each resident receives an accurate assessment. Health 2023-03-17 2023-04-13 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 2023-03-17 2023-04-13 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 2023-03-17 2023-04-13 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-03-17 2023-04-13 N
Provide care or services that was trauma informed and/or culturally competent. Health 2023-03-17 2023-04-13 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-03-17 2023-04-13 N
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Health 2023-03-17 2023-04-13 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 2023-03-17 2023-04-13 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 2023-03-17 2023-04-13 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 2023-03-17 2023-04-13 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-03-17 2023-04-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-03-17 2023-04-13 N
Implement a program that monitors antibiotic use. Health 2023-03-17 2023-04-13 N
Ensure staff are vaccinated for COVID-19 Health 2023-03-17 2023-04-13 N
Install a two-hour-resistant firewall separation. Fire Safety 2023-03-28 2023-04-13 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2023-03-28 2023-04-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-03-28 2023-04-13 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 2023-01-03 2023-02-16 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-10-27 2022-11-29 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2022-04-07 2022-06-07 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-07 2022-06-07 Y
Ensure staff are vaccinated for COVID-19 Health 2022-04-07 2022-06-07 Y
Ensure each resident receives an accurate assessment. Health 2022-05-06 2022-06-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-06 2022-06-07 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 2022-05-06 2022-06-07 N
Provide enough food/fluids to maintain a resident's health. Health 2022-05-06 2022-06-07 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-05-06 2022-06-07 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2022-05-06 2022-06-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-05-06 2022-06-07 N
Provide and implement an infection prevention and control program. Health 2022-05-06 2022-06-07 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-05-24 2022-06-07 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-05-24 2022-06-07 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-24 2022-06-07 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-05-24 2022-06-07 N

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