A list of the most recent deficiencies for Ellen Memorial Health Care 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-10-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-29 | 2023-10-05 | Y |
| 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 | 2023-03-17 | 2023-04-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-17 | 2023-04-13 | 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 | 2023-03-17 | 2023-04-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-17 | 2023-04-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-17 | 2023-04-13 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-17 | 2023-04-13 | 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 | 2023-03-17 | 2023-04-13 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-03-17 | 2023-04-13 | 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 | 2023-03-17 | 2023-04-13 | 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 | 2023-03-17 | 2023-04-13 | 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 | 2023-03-17 | 2023-04-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-17 | 2023-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-17 | 2023-04-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-17 | 2023-04-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-17 | 2023-04-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-04-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-16 | 2023-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-04-13 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-03-28 | 2023-04-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-28 | 2023-04-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-04-13 | 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 | 2023-01-03 | 2023-02-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-27 | 2022-11-29 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-07 | 2022-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-06-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-07 | 2022-06-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-06 | 2022-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-06 | 2022-06-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-06 | 2022-06-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-06 | 2022-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-06 | 2022-06-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-05-06 | 2022-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-06 | 2022-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-06 | 2022-06-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-24 | 2022-06-07 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-10 | 2021-10-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-17 | 2021-08-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-17 | 2021-08-10 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-17 | 2021-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-08-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-17 | 2021-08-10 | N |
| 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 | 2021-06-17 | 2021-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-08-10 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-22 | 2021-08-10 | N |
