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Deficiency Records for Elmhaven East
View the most recent health deficiencies and inspection results for Elmhaven East. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Elmhaven East. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2025-04-23 | 2025-06-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-04-23 | 2025-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-04-23 | 2025-06-24 | 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 | 2025-04-23 | 2025-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-04-23 | 2025-06-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-04-23 | 2025-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-04-23 | 2025-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-04-23 | 2025-05-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-04-23 | 2025-05-28 | Y |
| 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 | 2025-04-23 | 2025-05-28 | Y |
| Post nurse staffing information every day. | Health | 2025-04-23 | 2025-05-28 | Y |
| 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 | 2025-04-23 | 2025-05-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-23 | 2025-05-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-04-23 | 2025-05-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-04-23 | 2025-05-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-04-23 | 2025-05-28 | Y |
| 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 | 2025-04-23 | 2025-05-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-04-23 | 2025-05-28 | Y |
| 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 | 2025-04-23 | 2025-05-28 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-10 | 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 | 2023-08-10 | 2023-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-10 | 2023-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-10 | 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 | 2023-08-10 | 2023-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-10 | 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 |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Use approved construction type or materials. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-21 | 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 | 2021-12-21 | 2022-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-21 | 2022-01-31 | N |
| Provide and implement an infection prevention and control program. | 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 |
| Post nurse staffing information every day. | 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 |
| Provide safe, appropriate pain management for a resident who requires such services. | 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 care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| 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 |
| 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 | N |