A list of the most recent deficiencies for Elmbrook of Hugo. 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? |
|---|---|---|---|---|
| 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 | 2023-12-07 | 2024-01-11 | 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 | 2023-12-07 | 2024-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-01-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-07 | 2024-01-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-07 | 2024-01-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-07 | 2023-12-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-07 | 2023-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-04-25 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2022-07-13 | 2022-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-15 | 2022-08-24 | 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 | 2022-07-15 | 2022-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-08-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-13 | 2022-08-24 | 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 | 2022-07-13 | 2022-08-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-13 | 2022-08-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-13 | 2022-08-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-13 | 2022-08-24 | N |
| Have an externally vented heating system. | Fire Safety | 2019-10-30 | 2019-12-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-31 | 2019-11-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-31 | 2019-11-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-31 | 2019-11-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-31 | 2019-11-22 | 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 | 2019-10-31 | 2019-11-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-31 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-30 | 2019-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2019-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-19 | 2018-10-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-19 | 2018-10-19 | N |
