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Deficiency Records for Elderwood at North Creek
A list of the most recent deficiencies for Elderwood at North Creek. 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 Elderwood at North Creek. 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 and appropriate respiratory care for a resident when needed. | Health | 2022-04-08 | 2022-06-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-07 | 2022-06-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-06-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-07 | 2022-06-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-01 | 2019-12-31 | 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 | 2019-11-01 | 2019-12-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-01 | 2019-12-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-01 | 2019-12-31 | 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 | 2019-11-01 | 2019-12-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-11-01 | 2019-12-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-01 | 2019-12-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-11-01 | 2019-12-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-01 | 2019-12-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-01 | 2019-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-01 | 2019-12-30 | 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 | 2018-05-25 | 2018-07-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-25 | 2018-07-24 | 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 | 2018-05-25 | 2018-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-25 | 2018-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-25 | 2018-07-24 | 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 | 2018-05-25 | 2018-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-25 | 2018-07-24 | N |
| Dispose of garbage and refuse properly. | Health | 2018-05-25 | 2018-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-25 | 2018-07-24 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-25 | 2018-07-24 | N |
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