A list of the most recent deficiencies for Elim Wellspring. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-19 | 2023-11-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-18 | 2023-11-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-19 | 2023-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-03 | 2022-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-31 | 2022-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-31 | 2022-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-31 | 2022-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-31 | 2022-12-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-31 | 2022-06-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-11 | 2021-04-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-11 | 2021-04-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-11 | 2021-04-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-03-11 | 2021-04-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-11 | 2021-04-23 | 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 | 2021-03-11 | 2021-04-23 | N |
| Keep all essential equipment working safely. | Health | 2021-03-11 | 2021-04-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-11 | 2021-04-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-11 | 2021-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-15 | 2021-04-09 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-03-15 | 2021-04-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-15 | 2021-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-15 | 2021-04-09 | N |
