A list of the most recent deficiencies for The Ellis Nursing 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-16 | 2023-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2023-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-20 | 2023-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-20 | 2023-01-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-20 | 2023-01-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-16 | 2023-01-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-16 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-01-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-16 | 2023-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-16 | 2023-01-20 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-12-16 | 2023-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-20 | 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 | 2022-12-16 | 2023-01-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-16 | 2023-01-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2023-01-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-12-16 | 2023-01-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-16 | 2023-01-20 | 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 | 2022-12-16 | 2023-01-20 | 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 | 2022-12-16 | 2023-01-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-16 | 2023-01-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-16 | 2023-01-20 | 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 | 2022-12-16 | 2023-01-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-30 | 2019-10-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-30 | 2019-10-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-30 | 2019-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-30 | 2019-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-30 | 2019-10-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-12 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-12 | 2019-09-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-12 | 2019-09-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-15 | 2018-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-15 | 2018-09-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-15 | 2018-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-15 | 2018-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-15 | 2018-09-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-15 | 2018-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-15 | 2018-09-26 | 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 | 2018-08-15 | 2018-09-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-15 | 2018-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-15 | 2018-09-21 | 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 | 2018-08-22 | 2018-09-14 | N |
| Dispose of garbage and refuse properly. | Health | 2018-08-22 | 2018-09-14 | N |
| Keep all essential equipment working safely. | Health | 2018-08-22 | 2018-09-14 | 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 | 2018-08-22 | 2018-09-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-22 | 2018-09-06 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-08-22 | 2018-08-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-22 | 2018-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-22 | 2018-08-31 | 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 | 2018-08-22 | 2018-08-29 | 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 | 2018-08-22 | 2018-08-23 | N |
