Deficiency Records for Elmhurst Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Elmhurst Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-21 | 2023-12-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-14 | 2023-12-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-14 | 2023-12-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-11 | 2023-10-04 | N |
| 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 | 2023-09-11 | 2023-10-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-11 | 2023-10-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-11 | 2023-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-11 | 2023-10-04 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-11 | 2023-10-04 | 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 | 2023-09-11 | 2023-10-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-11 | 2023-10-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-11 | 2023-10-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-11 | 2023-10-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-16 | 2023-09-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-16 | 2023-09-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-20 | 2023-08-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-19 | 2023-07-10 | Y |
| 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 | 2023-06-19 | 2023-07-10 | 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 | 2023-06-19 | 2023-07-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-19 | 2023-07-10 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-24 | 2023-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-24 | 2023-04-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-24 | 2023-04-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-04-23 | 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 | 2023-03-24 | 2023-04-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-24 | 2023-04-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-24 | 2023-04-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-24 | 2023-04-23 | 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 | 2023-03-24 | 2023-04-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-24 | 2023-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-24 | 2023-04-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-24 | 2023-04-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-24 | 2023-04-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-24 | 2023-04-23 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-03-24 | 2023-04-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-24 | 2023-04-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-10 | 2023-04-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-10 | 2023-04-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-24 | 2023-03-03 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-01-13 | 2023-02-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-07 | 2022-12-01 | Y |
| 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 | 2022-10-13 | 2022-11-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-13 | 2022-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-11-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-23 | 2022-10-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-23 | 2022-10-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-23 | 2022-10-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-10-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-23 | 2022-10-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-23 | 2022-10-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-10-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-23 | 2022-10-23 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-09-23 | 2022-10-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-09-23 | 2022-10-23 | 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 | 2022-09-23 | 2022-10-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-23 | 2022-10-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-23 | 2022-10-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-13 | 2022-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-31 | 2022-04-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-31 | 2022-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-31 | 2022-04-30 | 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 | 2022-03-31 | 2022-04-30 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-03-31 | 2022-04-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-31 | 2022-04-30 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-31 | 2022-04-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-31 | 2022-04-30 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-03-31 | 2022-04-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-24 | 2022-02-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-14 | 2021-12-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-18 | 2021-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-02 | 2021-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-11-30 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-11-02 | 2021-11-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-02 | 2021-11-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-02 | 2021-11-27 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-11-02 | 2021-11-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-01 | 2021-09-24 | 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 | 2021-08-24 | 2021-09-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-07 | 2021-08-06 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-07-07 | 2021-08-06 | 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 | 2021-07-07 | 2021-08-06 | Y |
