A list of the most recent deficiencies for Ephrata Manor. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-03 | 2023-11-30 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-03 | 2023-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2023-11-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-03 | 2023-11-30 | 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 | 2023-11-03 | 2023-11-30 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-03 | 2023-11-30 | 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 | 2023-10-17 | 2023-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-11-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-17 | 2023-11-03 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-28 | 2023-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-28 | 2023-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-28 | 2023-01-31 | 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 | 2022-12-16 | 2023-01-30 | 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 | 2022-12-16 | 2023-01-30 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-04 | 2021-12-04 | 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 | 2021-11-04 | 2021-12-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-04 | 2021-12-04 | N |
