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Deficiency Records for Elizabeth Church Manor Nursing Home
View the most recent health deficiencies and inspection results for Elizabeth Church Manor Nursing Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Elizabeth Church Manor Nursing Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-08-01 | 2025-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-08-01 | 2025-12-02 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-08-01 | 2025-09-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-01 | 2025-09-26 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2025-08-01 | 2025-09-26 | N |
| Dispose of garbage and refuse properly. | Health | 2025-08-01 | 2025-09-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-01 | 2025-09-26 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2025-08-01 | 2025-09-26 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-08-01 | 2025-09-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-01 | 2025-09-26 | 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 | 2025-08-01 | 2025-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-08-01 | 2025-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-22 | 2024-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-22 | 2024-11-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-22 | 2024-11-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-22 | 2024-11-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-08-22 | 2024-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-30 | 2024-11-06 | Y |
| 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 | 2024-09-30 | 2024-11-06 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-09-30 | 2024-11-06 | 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 | 2024-08-22 | 2024-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-22 | 2024-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-22 | 2024-10-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-08-22 | 2024-10-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-22 | 2024-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-22 | 2024-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-22 | 2024-10-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-22 | 2024-10-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-22 | 2024-10-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-22 | 2024-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-22 | 2024-10-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-08-22 | 2024-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-22 | 2024-10-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-22 | 2024-10-21 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-10 | 2024-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-10 | 2024-05-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-01 | 2022-10-28 | N |
| Post nurse staffing information every day. | Health | 2022-09-01 | 2022-10-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-01 | 2022-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-01 | 2022-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-01 | 2022-09-30 | N |