A list of the most recent deficiencies for Eastern Star Masonic 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 and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-19 | 2023-10-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-19 | 2023-10-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-19 | 2023-10-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-19 | 2023-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-19 | 2023-10-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-19 | 2023-10-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-19 | 2023-10-02 | 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 | 2023-09-14 | 2023-10-01 | 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 | 2023-09-14 | 2023-10-01 | 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 | 2023-09-14 | 2023-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-09-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-19 | 2023-09-26 | 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 | 2023-09-19 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-19 | 2023-09-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-09-19 | 2023-09-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-19 | 2023-09-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-03-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-03-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-09 | 2023-03-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-03-17 | 2022-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-17 | 2022-03-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-03-05 | 2020-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-05 | 2020-04-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-27 | 2020-03-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-27 | 2020-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-27 | 2020-03-27 | 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 | 2020-02-27 | 2020-03-27 | 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 | 2020-02-27 | 2020-03-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-27 | 2020-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-03-27 | N |
