A list of the most recent deficiencies for Elmhaven East. 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? |
|---|---|---|---|---|
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Use approved construction type or materials. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-12 | 2023-10-16 | 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 | 2023-09-12 | 2023-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-12 | 2023-10-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-10 | 2023-09-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-08-10 | 2023-09-22 | 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 | 2023-08-10 | 2023-09-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-09-22 | 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 | 2023-08-10 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-22 | 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 | 2023-08-10 | 2023-09-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-10 | 2023-09-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-10 | 2023-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-09-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-11 | 2023-06-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-17 | 2022-12-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-17 | 2022-12-19 | 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 | 2022-11-17 | 2022-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2022-12-19 | 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 | 2022-04-20 | 2022-05-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-11 | 2022-01-31 | 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 | 2022-01-11 | 2022-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-11 | 2022-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-21 | 2022-01-13 | 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 | 2021-12-21 | 2022-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-21 | 2022-01-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-21 | 2022-01-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-12-21 | 2022-01-13 | N |
| Post nurse staffing information every day. | Health | 2021-12-21 | 2022-01-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-12-21 | 2022-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-13 | 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 | 2021-12-21 | 2022-01-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-21 | 2022-01-13 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-12-01 | 2021-12-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-21 | 2021-08-10 | 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 | 2021-07-21 | 2021-08-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-03 | 2020-04-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-03-03 | 2020-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-03 | 2020-04-05 | 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 | 2020-03-03 | 2020-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-03 | 2020-04-05 | 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 | 2020-03-03 | 2020-04-05 | 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 | 2020-03-03 | 2020-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-03 | 2020-04-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-09 | 2020-02-07 | N |
