Elm Crest Manor

In the surveyor’s words

From the most serious findings on record at Elm Crest Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Jan 8, 2025

  Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#3) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 01/06/25 at 11: 55 a.m., the dietary supervisor (#3) stated she is enrolled in the Certified Dietary Manager (CDM) course, but has not competed the training. During an interview on 01/07/25 at 10:40 a.m., an administrative staff member (#2) confirmed the dietary supervisor (#3) lacked the required training for the position. […]

• No harm, potential for more than minimal, patternF761Nov 21, 2023

  Based on observation and facility policy, the facility failed to assure safe and secure storage of narcotic medications for 2 of 2 medication carts. Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Drugs occurred on 11/21/23. This policy, dated 03/04/20, stated, . Strict control of narcotics is maintained always. Procedures: . All controlled medications are kept under double-lock and in a separate drawer (also known as the narcotic drawer) from other medications. Observation on 11/20/23 at 2:30 p.m. […]

• No harm, potential for more than minimal, patternF812Nov 3, 2022

  Based on observation, review of professional literature, and staff interview, facility staff failed to prepare and serve foods under sanitary conditions in 1 of 1 kitchen. Failure to serve food in a sanitary manner may result in forborne illness to residents, staff, and visitors. Findings include: The Food Code, U.S. Public Health Service, Food and Drug Administration, U.S. Department of Health and Human Services, 2017, page 78, stated, . SINGLE-USE gloves shall be used for only one task . […]

• No harm, potential for more than minimal, isolatedF641Jan 22, 2026

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #16). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 through A-32, stated, .A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . […]

• No harm, potential for more than minimal, isolatedF684Jan 22, 2026

  Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure appropriate care and services for 1 of 3 sampled residents (Resident #14) reviewed for edema (fluid retention). Failure to ensure consistent implementation of support stockings and document resident refusals, may result in worsening edema.Findings include:Review of policy, Compression Stockings occurred on 01/22/26. This policy, dated 11/05/19, stated, . Compression stockings are applied appropriately to aid circulation to lower extremities and to help prevent edema. applied by nursing personnel . Chart if resident refuses stockings.Review of Resident #14's medical record occurred on all days of survey. […]