Deficiency Records for Elm Manor Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Elm Manor Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| 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 | 2023-02-01 | 2023-03-30 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-02-01 | 2023-03-30 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-24 | 2023-01-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-24 | 2023-01-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-24 | 2023-01-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-24 | 2023-01-18 | 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 | 2022-10-24 | 2023-01-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-24 | 2023-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-24 | 2023-01-18 | 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 | 2022-10-24 | 2023-01-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-24 | 2023-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-24 | 2023-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-24 | 2023-01-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-24 | 2023-01-18 | 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 | 2022-10-24 | 2023-01-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-24 | 2023-01-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-16 | 2021-11-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2020-11-02 | 2020-11-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-11-02 | 2020-11-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-11-02 | 2020-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-02 | 2020-11-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-11-02 | 2020-11-28 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-10-30 | 2020-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-30 | 2020-11-28 | N |
| 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 | 2019-04-12 | 2019-07-19 | N |
| Post nurse staffing information every day. | Health | 2019-04-12 | 2019-07-19 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-04-12 | 2019-07-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-12 | 2019-06-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-04-12 | 2019-06-11 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-12 | 2019-06-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-12 | 2019-06-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-12 | 2019-06-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-12 | 2019-06-11 | 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 | 2019-04-12 | 2019-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-12 | 2019-06-11 | N |
