A list of the most recent deficiencies for The Elms. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-25 | 2024-02-15 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-01 | 2023-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-03-13 | 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 | 2023-02-24 | 2023-03-13 | 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 | 2022-12-07 | 2022-12-22 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-01-06 | 2022-01-30 | 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 | 2022-01-06 | 2022-01-30 | 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 | 2022-01-06 | 2022-01-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-28 | 2021-09-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-28 | 2021-09-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-28 | 2021-06-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-06-11 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-13 | 2020-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-13 | 2020-11-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Develop a communication plan. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Establish methods for sharing information. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-13 | 2020-10-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-10-13 | 2020-10-29 | 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 | 2020-10-08 | 2020-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-10-08 | 2020-10-08 | N |
