Elk Haven Nursing Home

In the surveyor’s words

From the most serious findings on record at Elk Haven Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF600May 9, 2024

  Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of spiral fractures of the right tibia and fibula (lower leg). This deficiency is cited as past non-compliance. Findings include: A review of facility policy entitled, Resident Abuse & Neglect Prevention Program, dated 1/10/2024, revealed that, Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• No harm, potential for more than minimal, isolatedF761May 29, 2026

  Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of three medication rooms reviewed (B Wing medication room ). Findings include: Review of facility policy entitled Storage of Medications dated 1/27/26, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of manufacturer's guidelines revealed that an open vial of Aplisol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. […]

• No harm, potential for more than minimal, isolatedF812May 29, 2026

  Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three resident pantries reviewed (B Wing). Findings include: A facility policy entitled Food Storage- Unit Pantries/Activity Kitchens dated 1/27/26, indicated that dining services will stock the unit refrigerators with supplements and snacks and discard outdated items as necessary; bulk milk, juices, drinks, and supplements shall be dated when opened and discarded after four days of date opened; and non-perishable items shall be discarded per the use by date on the label provided that they are properly sealed, stored within the correct temperatures, and show no signs of deterioration. […]

• No harm, potential for more than minimal, isolatedF605May 15, 2025

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R20). Findings include: Review of facility policy entitled Psychotropic Medication Policy dated 1/21/25, revealed the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication. […]

• No harm, potential for more than minimal, isolatedF657May 15, 2025

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 20 residents reviewed (Residents R10 and R16). Findings include: Review of facility policy entitled Comprehensive Person-Centered Care Planning dated 1/21/25, indicated The care plans will be reviewed and revised as necessary by the Interdisciplinary Team at least quarterly after each MDS [Minimum Data Set-a periodic assessment of resident care needs] assessment ., or more often as changes occur. […]