Elm Crest Retirement Community

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 10, 2026

  Based on clinical record review, facility investigation file review, resident and staff interviews, and policy review the facility staff failed to follow the facility's fall policy and protocol to notify the charge nurse in order to complete an assessment in a timely manner and begin interventions after a resident had a fall for one of three residents reviewed for injuries of unknown origin and nursing supervision (Resident #1). The facility reported a census of 41 residents. The facility corrected the deficient practice per past noncompliance on 2/17/26 through the following actions: *The facility DON and Administrator began an investigation when the bruises were discovered on Resident #1 on 2/4/26.*The facility sent Resident #1 to the Emergency Department (ED) on 2/4/26 for evaluation. […]

• Actual harm, isolatedF689Nov 14, 2024

  Based on clinical record review, observation, facility document review, staff interviews and facility policy review, the facility failed to use safe transfer techniques for 1 of 3 residents. Resident #37 had fell in the bathroom and sustained bruising and a skin tear after staff assisted him without the use of a gait belt or proper footwear. The facility also failed to implement new interventions with repeat falls to reduce the risk for Resident #37. The facility reported a census of 43 residents. […]

• No harm, potential for more than minimal, patternF804Jan 14, 2026

  Based on observation, resident interview, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 47 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Interview on 1/11/26 at 12:16 PM with Resident #1 revealed that the food is often cold when it should be warm. 2. Review of Resident #13's MDS dated [DATE] revealed a BIMS score of 13 out of 15, indicating intact cognitive functioning. Interview on 1/11/26 at 2:20 PM with Resident #13 revealed that the food is not always warm. 3. […]

• No harm, potential for more than minimal, patternF805Jan 14, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents were served meals according to the residents' specific needs for 5 of 46 residents reviewed. The facility reported a census of 47 residents. Findings include: The facility Menu for Week 3 of a 4-week rotation, showed that on 1/12/26 the lunch meal would include: diced chicken on rice, topped with sweet and sour sauce, stir fry vegetables, fortune cookie and fruit cocktail. The Mechanical Soft (texture modified foods for people who have soft and easy to eat if resident has difficulty swallowing) therapeutic menu showed that the chicken would be ground, no changes with the rice or the sauce, broccoli florets instead of the stir fry veggies, omit the fortune cookie and substitute peach and or pears… […]

• No harm, potential for more than minimal, patternF812Jan 14, 2026

  Based on observations, staff interviews, and policy review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to maintain a clean kitchen environment. The facility reported a census of 47 residents. Findings include: Continuous observation on 1/11/26 at 9:35 AM during the initial kitchen walk through identified the following concerns: a. The chocolate milk cooler contained dirty crates, walls with the appearance of spilled chocolate milk and a black residual along the hinge of the lid. The cooler did not contain an internal thermometer.b. The cooler containing white milk, sour cream and cottage cheese displayed frost along the inside cooler walls. The thermometer was upside down. c. […]