A list of the most recent deficiencies for The Earlwood. 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 | 2023-12-21 | 2024-01-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-11-27 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-27 | 2023-11-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-27 | 2023-11-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-27 | 2023-11-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-27 | 2023-11-27 | 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 | 2023-10-27 | 2023-11-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-27 | 2023-11-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-27 | 2023-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-11-27 | 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 | 2023-10-27 | 2023-11-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-27 | 2023-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-11-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-27 | 2023-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-11-27 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2023-10-27 | 2023-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-25 | 2023-11-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-28 | 2023-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-15 | 2023-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-15 | 2023-09-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-15 | 2023-09-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-29 | 2023-08-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-06 | 2023-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-26 | 2023-06-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-26 | 2023-06-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-08 | 2022-12-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-08 | 2022-12-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-08 | 2022-12-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-08 | 2022-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2022-12-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-08 | 2022-12-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-08 | 2022-12-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-08 | 2022-12-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-08 | 2022-12-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-08 | 2022-12-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-08 | 2022-12-31 | 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 | 2022-12-08 | 2022-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-08 | 2022-12-31 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-12-08 | 2022-12-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-08 | 2022-12-31 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-05-11 | 2022-05-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-06 | 2022-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2022-01-19 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-10-26 | 2021-11-02 | 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 | 2019-04-19 | 2019-05-14 | 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 | 2019-04-19 | 2019-05-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-19 | 2019-05-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-19 | 2019-05-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-19 | 2019-05-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-19 | 2019-05-14 | 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 | 2019-04-19 | 2019-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-19 | 2019-05-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-19 | 2019-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-19 | 2019-05-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-19 | 2019-05-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-19 | 2019-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-17 | 2019-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-17 | 2019-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-17 | 2019-05-13 | N |
