A list of the most recent deficiencies for Elaine Center at Hadley. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-11-14 | 2023-12-27 | 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 | 2023-11-14 | 2023-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-14 | 2023-12-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-02 | 2023-12-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-02 | 2023-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-02 | 2023-12-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-02 | 2023-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-09 | 2022-11-28 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-09 | 2022-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-05 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-05 | 2022-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-05 | 2022-05-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-05 | 2022-05-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-05 | 2022-05-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-05 | 2022-05-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-05 | 2022-05-13 | 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 | 2022-04-05 | 2022-05-13 | 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 | 2022-04-05 | 2022-05-13 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-04-05 | 2022-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-11 | 2022-02-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-11 | 2022-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-11 | 2022-02-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-11-10 | 2021-12-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-02 | 2021-05-16 | 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 | 2021-04-02 | 2021-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-02 | 2021-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-02 | 2021-05-16 | 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 | 2021-04-05 | 2021-04-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-05 | 2021-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-05 | 2021-04-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-02 | 2021-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-02 | 2021-03-29 | N |
