Deficiency Records for Windsor Elmhaven Care Center
Updated as of June 01, 2023
This is not the most recent data for Windsor Elmhaven Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Windsor Elmhaven 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-28 | 2023-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-03-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-16 | 2023-03-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-01 | 2023-03-24 | Y |
| 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 | 2023-03-01 | 2023-03-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-17 | 2023-03-23 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-27 | 2023-03-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-29 | 2022-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-12 | 2022-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-20 | 2022-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-20 | 2022-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-07 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-06 | 2022-10-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-20 | 2022-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-20 | 2022-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-22 | 2022-09-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-16 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-12 | 2022-07-22 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-12 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-07 | 2022-03-31 | N |
| Report COVID19 data to residents and families. | Health | 2022-03-07 | 2022-03-31 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-07 | 2022-03-31 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-07 | 2022-03-31 | N |
| Keep all essential equipment working safely. | Health | 2022-03-07 | 2022-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-26 | 2022-02-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-26 | 2022-02-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-23 | 2022-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-28 | 2021-12-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-01 | 2021-10-20 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-30 | 2021-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-19 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-21 | 2021-10-19 | 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 | 2021-09-08 | 2021-10-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-09-08 | 2021-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-09-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-26 | 2021-09-13 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-18 | 2021-06-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-18 | 2021-06-30 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-18 | 2021-06-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-25 | 2021-04-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-03 | 2021-04-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-03 | 2021-03-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-02-03 | 2021-03-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-12-09 | 2021-01-10 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-12-09 | 2021-01-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-08-25 | 2020-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-25 | 2020-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-28 | 2020-10-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-09-09 | 2020-10-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-09 | 2020-10-26 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-09-01 | 2020-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-08 | 2020-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-12 | 2020-09-11 | 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 | 2019-06-20 | 2019-08-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-20 | 2019-08-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-20 | 2019-08-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-20 | 2019-08-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-08-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-20 | 2019-08-28 | 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 | 2019-06-20 | 2019-08-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-20 | 2019-08-28 | 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 | 2019-06-20 | 2019-08-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-06-20 | 2019-08-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-20 | 2019-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-08-28 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2019-06-20 | 2019-08-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-08 | 2019-08-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-17 | 2018-08-02 | 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 | 2018-07-17 | 2018-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-08 | 2018-07-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | 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 | 2018-06-08 | 2018-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-08 | 2018-07-05 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-06-23 | 2017-08-01 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-06-23 | 2017-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-23 | 2017-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-23 | 2017-08-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-23 | 2017-08-01 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-06-23 | 2017-08-01 | N |
| Use approved construction type or materials. | Fire Safety | 2017-07-06 | 2017-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-06 | 2017-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-06 | 2017-07-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-07-06 | 2017-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-07-06 | 2017-07-31 | N |
