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Deficiency Records for Eliseo
A list of the most recent deficiencies for Eliseo. 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 Eliseo. 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 | 2024-09-18 | 2024-11-02 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-06-05 | 2024-08-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-05 | 2024-08-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-05 | 2024-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-05 | 2024-08-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-05 | 2024-07-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-05 | 2024-07-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-05 | 2024-07-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-05 | 2024-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-05 | 2024-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-05 | 2024-07-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-05 | 2024-07-20 | 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 | 2024-06-05 | 2024-07-20 | 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 | 2024-06-05 | 2024-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-05 | 2024-07-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-05 | 2024-07-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-06-05 | 2024-07-20 | N |
| Keep all essential equipment working safely. | Health | 2024-06-05 | 2024-07-20 | 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 | 2024-06-05 | 2024-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-05 | 2024-07-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-06-05 | 2024-07-10 | 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 | 2024-06-05 | 2024-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-05 | 2024-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-12 | 2024-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-12 | 2024-04-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-04 | 2023-12-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-15 | 2023-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-15 | 2023-10-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-15 | 2023-10-16 | N |
| Provide large enough exits. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-15 | 2023-10-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-10-04 | 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 | 2023-08-17 | 2023-10-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-17 | 2023-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-17 | 2023-10-04 | 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 | 2023-08-17 | 2023-10-04 | 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 | 2023-08-17 | 2023-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-10-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-17 | 2023-10-04 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-15 | 2023-09-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-04 | 2023-05-17 | 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 | 2023-01-06 | 2023-02-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-16 | 2022-12-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-12 | 2022-06-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-12 | 2022-06-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-12 | 2022-06-23 | 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 | 2022-05-12 | 2022-06-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-12 | 2022-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-06-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-12 | 2022-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-12 | 2022-06-23 | 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 | 2022-05-12 | 2022-06-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-12 | 2022-06-23 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-12 | 2022-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-11 | 2022-06-15 | 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 | 2022-05-11 | 2022-06-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-11 | 2022-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-03-14 | Y |
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