Deficiency Records for Windsor Elk Grove Care and Rehabilitation Center
Updated as of February 01, 2022
This is not the most recent data for Windsor Elk Grove Care and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-02-18 | 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 other general requirements that are deficient. | 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 |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-02 | 2019-07-16 | Y |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-05-07 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-02-15 | 2019-03-15 | Y |
| 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 | 2019-02-15 | 2019-03-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-19 | 2018-08-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-07-19 | 2018-08-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-07-19 | 2018-08-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-19 | 2018-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-19 | 2018-08-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-07-19 | 2018-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-19 | 2018-08-16 | N |
| Use approved construction type or materials. | Fire Safety | 2018-07-26 | 2018-08-06 | 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 | 2018-07-26 | 2018-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-26 | 2018-08-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-26 | 2018-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-26 | 2018-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-26 | 2018-08-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-26 | 2018-08-06 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-06-23 | 2017-07-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-06-23 | 2017-07-19 | N |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-06-23 | 2017-07-19 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-06-23 | 2017-07-19 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-23 | 2017-07-19 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-06-23 | 2017-07-19 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-06-23 | 2017-07-19 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-06-23 | 2017-07-19 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-06-23 | 2017-07-19 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-23 | 2017-07-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-06-23 | 2017-07-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-06-23 | 2017-07-19 | N |
| Use approved construction type or materials. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-07-05 | 2017-07-19 | N |
