A list of the most recent deficiencies for Elizabeth 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-06 | 2023-01-25 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-07 | 2023-01-23 | 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 | 2022-12-07 | 2023-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-07 | 2023-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-07 | 2023-01-23 | 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 | 2022-12-07 | 2023-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-07 | 2023-01-23 | 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 | 2022-12-07 | 2023-01-23 | 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 | 2022-12-07 | 2023-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-07 | 2023-01-23 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-07 | 2023-01-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-18 | 2021-09-27 | 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 | 2021-08-18 | 2021-09-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-18 | 2021-09-27 | 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 | 2021-08-18 | 2021-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-18 | 2021-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-18 | 2021-09-27 | 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 | 2021-08-18 | 2021-09-27 | 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 | 2021-08-18 | 2021-09-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-18 | 2021-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-18 | 2021-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-09-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-15 | 2021-07-02 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-09-01 | 2020-09-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-09-01 | 2020-09-21 | 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 | 2020-09-01 | 2020-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-01 | 2020-09-05 | N |
