A list of the most recent deficiencies for Elmhurst Extended 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-05 | 2023-12-06 | 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 | 2023-12-05 | 2023-12-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-05 | 2023-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2023-12-06 | 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 | 2023-11-29 | 2023-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-29 | 2023-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-29 | 2023-12-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2023-12-05 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-29 | 2023-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-29 | 2023-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2023-12-05 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-29 | 2023-12-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-05 | 2023-12-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-26 | 2023-01-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-26 | 2023-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-26 | 2023-01-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2023-01-11 | 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 | 2022-11-17 | 2023-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2023-01-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-11-17 | 2022-12-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-17 | 2022-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2022-12-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-17 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-17 | 2022-11-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-17 | 2022-11-21 | 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 | 2022-11-17 | 2022-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-17 | 2022-11-21 | N |
| Report COVID19 data to residents and families. | Health | 2022-07-14 | 2022-08-26 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-29 | 2021-11-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-29 | 2021-11-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-29 | 2021-11-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-29 | 2021-11-17 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-09-29 | 2021-11-17 | N |
| Develop a communication plan. | Fire Safety | 2021-09-29 | 2021-11-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-29 | 2021-11-17 | 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 | 2021-09-29 | 2021-11-01 | 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 | 2021-09-29 | 2021-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-11-01 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-08-19 | 2021-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-15 | 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 | 2021-08-19 | 2021-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-19 | 2021-09-03 | N |
