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Deficiency Records for South Elgin Rehab and Hcc
A list of the most recent deficiencies for South Elgin Rehab and Hcc. 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 South Elgin Rehab and Hcc. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-11 | 2024-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2024-12-31 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-04-25 | 2024-07-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-07-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-31 | 2024-07-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-05-31 | 2024-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-31 | 2024-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-05-31 | 2024-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-11 | 2024-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-11 | 2024-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-04-25 | 2024-07-09 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-11 | 2024-07-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-11 | 2024-07-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-11 | 2024-07-02 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-06-11 | 2024-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-11 | 2024-07-01 | 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 | 2024-06-11 | 2024-07-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-11 | 2024-07-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-11 | 2024-07-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-31 | 2024-06-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-31 | 2024-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-31 | 2024-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-06-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-31 | 2024-06-28 | 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 | 2024-05-31 | 2024-06-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-31 | 2024-06-28 | 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 | 2024-05-31 | 2024-06-28 | 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 | 2024-05-31 | 2024-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-31 | 2024-06-28 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-05-31 | 2024-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-31 | 2024-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-11 | 2024-06-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-06-11 | 2024-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-11 | 2024-06-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-25 | 2024-05-24 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-25 | 2024-05-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-01 | 2024-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-25 | 2024-04-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-06 | 2024-03-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-06 | 2024-03-25 | 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 | 2024-03-06 | 2024-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-14 | 2024-02-29 | Y |
| 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 | 2024-02-01 | 2024-02-01 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-20 | 2023-10-06 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-27 | 2023-07-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-27 | 2023-07-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-27 | 2023-07-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-27 | 2023-07-07 | 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 | 2023-06-27 | 2023-07-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-27 | 2023-07-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-27 | 2023-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-27 | 2023-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-27 | 2023-07-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-27 | 2023-06-30 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-06-27 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-27 | 2023-06-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-27 | 2023-06-27 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-06-08 | 2023-06-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-08 | 2023-06-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-06-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-06-15 | 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 | 2023-06-08 | 2023-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-15 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-06-08 | 2023-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-06-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-26 | 2022-10-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-26 | 2022-10-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-26 | 2022-10-25 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-04-21 | 2022-05-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-28 | 2022-05-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-10 | 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 | 2022-04-28 | 2022-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-05-10 | 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 | 2022-04-28 | 2022-05-10 | 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 | 2022-04-28 | 2022-05-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-04-28 | 2022-05-10 | 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 | 2022-04-28 | 2022-05-10 | 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 | 2022-04-28 | 2022-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-28 | 2022-05-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-28 | 2022-05-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Develop a communication plan. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-03 | 2022-05-10 | 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 | 2022-05-03 | 2022-05-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-05-03 | 2022-05-10 | N |
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