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Deficiency Records for Elmwood Care Center
A list of the most recent deficiencies for Elmwood 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 Elmwood 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-03-06 | 2024-03-31 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-06 | 2024-03-31 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-06 | 2024-03-31 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-06 | 2024-03-31 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-06 | 2024-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-26 | 2023-07-26 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-01-19 | 2023-01-19 | Y |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-19 | 2023-01-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-28 | 2022-10-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-28 | 2022-10-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-28 | 2022-10-10 | 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 | 2022-07-28 | 2022-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-28 | 2022-10-10 | 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 | 2022-07-28 | 2022-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-28 | 2022-10-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-28 | 2022-10-10 | 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 | 2022-07-28 | 2022-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-28 | 2022-10-10 | N |
| Dispose of garbage and refuse properly. | Health | 2022-07-28 | 2022-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-10-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-07-28 | 2022-10-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-15 | 2022-09-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-15 | 2022-09-03 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-01 | 2022-08-22 | 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 | 2022-08-01 | 2022-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-01 | 2022-08-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-04 | 2020-03-04 | 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 | 2020-02-04 | 2020-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-04 | 2020-03-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-04 | 2020-03-04 | 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 | 2019-12-12 | 2020-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-12 | 2020-01-12 | N |
| Post nurse staffing information every day. | Health | 2019-12-12 | 2020-01-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-12 | 2020-01-12 | 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 | 2019-01-10 | 2019-01-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-10 | 2019-01-29 | 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 | 2019-01-10 | 2019-01-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-01-10 | 2019-01-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-10 | 2019-01-29 | 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 | 2018-10-25 | 2018-11-25 | 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 | 2018-10-25 | 2018-11-25 | 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 | 2018-10-25 | 2018-11-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-25 | 2018-11-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-25 | 2018-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-25 | 2018-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-25 | N |
| Keep all essential equipment working safely. | Health | 2018-10-25 | 2018-11-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-25 | 2018-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-24 | Not Fixed | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-24 | Not Fixed | N |
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