Deficiency Records for Windsor Elk Grove Care and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Windsor Elk Grove Care and Rehabilitation 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-16 | 2024-03-12 | 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 | 2024-02-16 | 2024-03-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-02-16 | 2024-03-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-16 | 2024-03-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-16 | 2024-03-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-16 | 2024-03-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-16 | 2024-03-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-16 | 2024-03-12 | 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 | 2024-02-16 | 2024-03-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-16 | 2024-03-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-16 | 2024-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-16 | 2024-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-16 | 2024-03-12 | N |
| Keep all essential equipment working safely. | Health | 2024-02-16 | 2024-03-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-16 | 2024-03-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-21 | 2024-03-12 | 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 | 2024-02-21 | 2024-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-21 | 2024-03-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-22 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-12-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-20 | 2023-10-27 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-10-20 | 2023-10-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-20 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-26 | 2023-07-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-25 | 2023-05-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-25 | 2023-05-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-05 | 2023-04-28 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-11 | 2023-02-10 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-11 | 2023-02-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-14 | 2023-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-06 | 2022-10-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-06 | 2022-10-27 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-08 | 2022-04-13 | 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 | 2022-03-08 | 2022-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-08 | 2022-04-13 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-03 | 2022-03-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-03 | 2022-03-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-03 | 2022-03-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-03 | 2022-03-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-03 | 2022-03-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-03-03 | 2022-03-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-03 | 2022-03-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-03 | 2022-03-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-22 | 2022-01-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-10-20 | 2021-11-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-05 | 2021-10-17 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-09 | 2019-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-24 | 2019-06-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-24 | 2019-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-24 | 2019-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-24 | 2019-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-06-20 | N |
