Deficiency Records for Big Elm Retirement and Nursing Centers
Updated as of April 01, 2024
A list of the most recent deficiencies for Big Elm Retirement and Nursing Centers. 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? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-26 | 2023-06-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-29 | 2023-04-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-29 | 2023-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-03-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-29 | 2023-03-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-29 | 2023-03-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-29 | 2023-03-29 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-07 | 2021-12-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-29 | 2021-11-20 | 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 | 2021-10-29 | 2021-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-29 | 2021-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-11-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-28 | 2020-03-10 | 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 | 2020-01-28 | 2020-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-28 | 2020-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-28 | 2020-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-28 | 2020-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-28 | 2020-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-28 | 2020-03-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-09 | 2020-02-07 | N |
| Post nurse staffing information every day. | Health | 2020-01-09 | 2020-02-07 | 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 | 2020-01-09 | 2020-02-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-09 | 2020-02-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-09 | 2020-02-07 | N |
