A list of the most recent deficiencies for Elmwood Care Centre. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-02-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-12 | 2024-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-12 | 2024-01-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-29 | 2023-08-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-29 | 2023-08-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-08-11 | 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 | 2023-06-29 | 2023-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-29 | 2023-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-08-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-29 | 2023-08-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-08-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-29 | 2023-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-08-11 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-03 | 2023-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-03 | 2023-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-03 | 2023-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-03 | 2023-07-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-31 | 2022-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-31 | 2022-09-30 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-31 | 2022-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-31 | 2022-09-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-31 | 2022-09-30 | Y |
| 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 | 2022-08-31 | 2022-09-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-12-16 | 2022-01-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-12-09 | 2022-01-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-09 | 2022-01-09 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-12-09 | 2022-01-09 | 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 | 2021-12-09 | 2022-01-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-09 | 2022-01-09 | 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 | 2021-12-09 | 2022-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-12-16 | 2021-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-07 | 2021-09-26 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-04 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-04 | 2020-01-03 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-12-04 | 2020-01-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-04 | 2020-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-04 | 2020-01-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-04 | 2020-01-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-04 | 2019-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2019-12-31 | 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 | 2019-11-21 | 2019-12-21 | 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 | 2019-11-21 | 2019-12-21 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-21 | 2019-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-21 | 2019-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-21 | 2019-12-21 | 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 | 2019-11-21 | 2019-12-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-21 | 2019-12-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-21 | 2019-12-21 | N |
| 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 | 2019-11-21 | 2019-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-04 | 2019-12-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-12-04 | 2019-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-04 | 2019-12-20 | 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 | 2019-12-04 | 2019-12-16 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-12-04 | 2019-12-13 | 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 | 2019-11-21 | 2019-12-12 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-12-04 | 2019-12-12 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-12-04 | 2019-12-09 | N |
