Deficiency Records for Eastern Star Masonic Home
Updated as of September 01, 2020
This is not the most recent data for Eastern Star Masonic Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | Y |
| 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-03-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-03 | 2019-05-24 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Be properly staffed | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-05 | 2019-04-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-28 | 2019-03-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-02-28 | 2019-03-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-28 | 2019-03-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-28 | 2019-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-03-28 | 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 | 2019-02-28 | 2019-03-28 | 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 | 2019-02-28 | 2019-03-28 | 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 | 2019-02-28 | 2019-03-28 | 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 | 2019-02-28 | 2019-03-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-02-28 | 2019-03-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-28 | 2019-03-28 | N |
| Use approved construction type or materials. | Fire Safety | 2017-11-15 | 2017-12-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-11-15 | 2017-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-11-15 | 2017-12-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-11-15 | 2017-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-11-15 | 2017-12-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-09 | 2017-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-11-09 | 2017-11-30 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-11-09 | 2017-11-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-09 | 2017-11-30 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2017-11-09 | 2017-11-30 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-06-15 | 2017-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-15 | 2017-07-07 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-06-15 | 2017-07-07 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-15 | 2017-07-07 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-15 | 2017-07-07 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-09-19 | 2016-11-28 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-19 | 2016-11-01 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-09-19 | 2016-09-23 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-19 | 2016-09-23 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-09-19 | 2016-09-23 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-09-19 | 2016-09-23 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-09-19 | 2016-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-19 | 2016-09-23 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-08-29 | 2016-09-16 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-08-29 | 2016-09-08 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-08-29 | 2016-09-07 | N |
| Portable fire extinguishers. | Fire Safety | 2016-08-29 | 2016-09-07 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-08-29 | 2016-09-07 | N |
