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Deficiency Records for Windsor Elmhaven Care Center
A list of the most recent deficiencies for Windsor Elmhaven Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Windsor Elmhaven 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-01 | 2024-08-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-01 | 2024-08-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-17 | 2024-08-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-17 | 2024-08-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-07-17 | 2024-08-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-07-17 | 2024-08-07 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-07-16 | 2024-08-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-11 | 2024-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-11 | 2024-06-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-30 | 2024-06-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-05-30 | 2024-06-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-10 | 2024-06-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-28 | 2024-06-02 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-05-28 | 2024-06-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-18 | 2024-04-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-15 | 2024-04-04 | Y |
| 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 | 2024-03-15 | 2024-04-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-03 | 2024-01-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-28 | 2024-01-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-11-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-24 | 2023-10-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-26 | 2023-10-17 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-26 | 2023-09-19 | 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 | 2023-07-26 | 2023-09-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-26 | 2023-09-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-20 | 2023-08-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-20 | 2023-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-07-20 | 2023-08-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-20 | 2023-08-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-20 | 2023-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-20 | 2023-08-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-20 | 2023-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-23 | 2023-06-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-28 | 2023-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-03-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-16 | 2023-03-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-01 | 2023-03-24 | 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 | 2023-03-01 | 2023-03-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-17 | 2023-03-23 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-27 | 2023-03-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-29 | 2022-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-12 | 2022-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-20 | 2022-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-20 | 2022-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-07 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-06 | 2022-10-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-20 | 2022-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-20 | 2022-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-22 | 2022-09-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-16 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-12 | 2022-07-22 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-12 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-07 | 2022-03-31 | N |
| Report COVID19 data to residents and families. | Health | 2022-03-07 | 2022-03-31 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-07 | 2022-03-31 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-07 | 2022-03-31 | N |
| Keep all essential equipment working safely. | Health | 2022-03-07 | 2022-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-26 | 2022-02-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-26 | 2022-02-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-23 | 2022-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-28 | 2021-12-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-01 | 2021-10-20 | Y |
| 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 | 2019-06-20 | 2019-08-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-20 | 2019-08-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-20 | 2019-08-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-20 | 2019-08-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-08-28 | 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 | 2019-06-20 | 2019-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-20 | 2019-08-28 | 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 | 2019-06-20 | 2019-08-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-20 | 2019-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2019-06-20 | 2019-08-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-17 | 2018-08-02 | 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 | 2018-07-17 | 2018-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-08 | 2018-07-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-08 | 2018-07-05 | N |
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