Deficiency Records for The Ellison John Transitional Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Ellison John Transitional 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 safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-21 | 2024-01-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-21 | 2024-01-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-21 | 2024-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-21 | 2024-01-21 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-12-28 | 2024-01-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-17 | 2024-01-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-17 | 2024-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-17 | 2024-01-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-17 | 2024-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-08 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-09-19 | 2023-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-09-27 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-15 | 2023-09-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-15 | 2023-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-15 | 2023-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-15 | 2023-09-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-15 | 2023-09-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-15 | 2023-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-07 | 2023-07-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-08 | 2023-07-07 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-04-30 | 2023-05-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-03 | 2023-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-04-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-02-03 | 2023-03-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-03 | 2023-03-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-03 | 2023-03-05 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-03 | 2023-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-03 | 2023-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-05 | 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 | 2023-02-03 | 2023-03-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-03 | 2023-03-05 | 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 | 2023-02-03 | 2023-03-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-03 | 2023-03-05 | 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 | 2023-02-03 | 2023-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-03 | 2023-03-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-02-03 | 2023-03-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-08 | 2023-03-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-08 | 2023-03-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-20 | 2023-02-20 | 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 | 2022-09-16 | 2022-10-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-16 | 2022-10-15 | Y |
| 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 | 2022-09-16 | 2022-10-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-16 | 2022-10-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-06 | 2022-09-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-16 | 2022-08-16 | Y |
| 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 | 2022-07-16 | 2022-08-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-16 | 2022-08-16 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-07-16 | 2022-08-16 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-24 | 2022-07-03 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-19 | 2022-06-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-19 | 2022-06-14 | 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 | 2022-02-25 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-03-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-03-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-02 | 2022-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-08 | 2022-01-15 | Y |
| 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 | 2021-12-08 | 2022-01-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-12-31 | 2022-01-07 | Y |
| 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 | 2021-12-31 | 2022-01-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-29 | 2022-01-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-26 | 2022-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-26 | 2022-01-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-21 | 2022-01-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-21 | 2022-01-07 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-13 | 2021-12-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-20 | 2021-11-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-19 | 2021-09-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-28 | 2021-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-28 | 2021-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-08-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-13 | 2021-07-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-03 | 2021-07-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-01 | 2021-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-01 | 2021-06-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-01 | 2021-06-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-15 | 2021-05-01 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-28 | 2021-04-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-28 | 2021-04-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-27 | 2021-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-27 | 2021-04-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-08 | 2021-03-29 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-11 | 2019-10-11 | 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 | 2019-09-11 | 2019-10-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-06 | 2019-09-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-06 | 2019-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-06 | 2019-09-30 | 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 | 2019-09-06 | 2019-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-06 | 2019-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-06 | 2019-09-30 | N |
| Post nurse staffing information every day. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-06 | 2019-09-30 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-06 | 2019-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-09-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-06 | 2019-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-09-07 | 2018-11-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-07 | 2018-11-02 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-09-07 | 2018-11-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-07 | 2018-11-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-09-07 | 2018-10-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-07 | 2018-10-11 | 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 | 2018-09-07 | 2018-10-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-09-07 | 2018-10-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-07 | 2018-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-07 | 2018-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-07 | 2018-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-07 | 2018-10-11 | 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 | 2018-09-07 | 2018-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-07 | 2018-10-11 | 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 | 2018-09-07 | 2018-10-11 | 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 | 2018-09-07 | 2018-10-11 | 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 | 2018-09-07 | 2018-10-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-07 | 2018-10-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-09-07 | 2018-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-07 | 2018-10-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-05 | 2018-10-01 | 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 | 2018-09-05 | 2018-10-01 | 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 | 2018-09-05 | 2018-10-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-05 | 2018-10-01 | 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 | 2018-09-05 | 2018-10-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-05 | 2018-10-01 | N |
