A list of the most recent deficiencies for Ely Manor. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-02 | 2024-02-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-23 | 2023-09-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-23 | 2023-09-13 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-23 | 2023-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-23 | 2023-09-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-23 | 2023-09-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-23 | 2023-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-23 | 2023-09-13 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-22 | 2023-09-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-22 | 2023-09-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-22 | 2023-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-05 | 2023-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-05 | 2023-08-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-05 | 2023-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-05 | 2023-07-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-05 | 2023-07-26 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-05 | 2023-07-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-05 | 2023-07-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-05 | 2023-07-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-12 | 2023-05-01 | 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 | 2023-04-12 | 2023-05-01 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-21 | 2022-10-21 | 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 | 2022-09-21 | 2022-10-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-21 | 2022-10-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-21 | 2022-10-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-21 | 2022-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-21 | 2022-10-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-13 | 2022-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-13 | 2022-10-07 | 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 | 2022-09-13 | 2022-10-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-13 | 2022-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-07 | 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 | 2022-09-13 | 2022-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-13 | 2022-10-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-13 | 2022-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-13 | 2022-10-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-13 | 2022-10-07 | 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 | 2022-09-13 | 2022-10-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-17 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-30 | 2021-07-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-30 | 2021-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-30 | 2021-07-24 | 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 | 2021-06-30 | 2021-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-30 | 2021-07-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-30 | 2021-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-30 | 2021-07-24 | 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 | 2021-06-30 | 2021-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-30 | 2021-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-30 | 2021-07-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-30 | 2021-07-24 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-28 | 2021-07-24 | N |
