A list of the most recent deficiencies for Elroy Health Services. 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? |
|---|---|---|---|---|
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-02-02 | 2024-03-15 | 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 | 2024-02-02 | 2024-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-02-02 | 2024-03-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-06 | 2024-02-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-06 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-06 | 2024-02-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-06 | 2024-02-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-06 | 2024-02-24 | 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 | 2023-12-13 | 2024-01-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-09 | 2023-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-03-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-15 | 2023-01-13 | 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 | 2022-12-15 | 2023-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-01-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-15 | 2023-01-13 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-14 | 2023-01-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-09 | 2022-03-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-03-10 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2022-02-09 | 2022-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-16 | 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 | 2021-08-19 | 2021-09-16 | 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 | 2021-08-19 | 2021-09-16 | 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 | 2021-08-19 | 2021-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-18 | 2021-09-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-18 | 2021-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-18 | 2021-09-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-18 | 2021-08-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-08-18 | 2021-08-18 | N |
