Elm Terrace Gardens

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF550Mar 27, 2025

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three of 19 sampled residents in one of two dining areas. (Second Floor) (Residents 18, 27, 54) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included Alzheimer's disease and dysphagia, oral phase (difficulty chewing before swallowing). Review of the Minimum Data Set (MDS) assessment, dated February 27, 2025, revealed that the resident had cognitive impairment and needed assistance from staff with eating. Review of Resident 18's care plan revealed that staff was to provide total assistance with feeding. […]

• No harm, potential for more than minimal, isolatedF641Mar 27, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed accurately to reflect the current status of one of 19 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 was admitted to the facility on [DATE]. Review of an admission nursing assessment, dated March 1, 2025, revealed a lack of evidence that the resident had a pressure ulcer upon admission. In an interview on March 26, 2025, at 11:10 a.m., Registered Nurse 1 stated that the resident did not have any pressure ulcers during his admission to the facility. […]

• No harm, potential for more than minimal, isolatedF812Mar 27, 2025

  Based on policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner in one of two dining areas (Second Floor). Findings include: Review of the facility's policy, Hand Washing/Hand Hygiene, dated January 7, 2025, revealed staff was expected to wash their hands and wear disposable gloves that are replaced between tasks during which they may have been soiled. On March 25, 2025, from 12:50 p.m. to 1:25 p.m. Dietary Aide 1 was observed wearing one pair of gloves to assist resident 27 with utensils, clear soiled plates, and assist with preparing plates of food for other residents. At no time did Dietary Aide 1 change gloves between tasks. […]

• No harm, potential for more than minimal, isolatedF656May 17, 2024

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement care planned interventions for one of 19 sampled residents. (Resident 13) Findings include: Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], and had diagnoses that included a stroke with remaining weakness to one side of the body and altered mental status. According to the Minimum Data Set assessment dated [DATE], the resident was cognitively impaired and had sustained falls on two occasions since admission. […]

• No harm, potential for more than minimal, isolatedF584Jun 1, 2023

  Based on observation, it was determined that the facility failed to provide a safe, sanitary and comfortable environment on two of four nursing units. (Nursing units D-1A and D-1B) Findings include: Observation throughout the facility during all days of the survey revealed the following: A lift (used to transfer residents from surface to surface) labeled 450 on Unit D-1A had dirty wheels. A lift labeled 600 on Unit D-1B had dirty wheels Observations on May 30, 2023, at 12:07 p.m., and May 31, 2023, at 12:25 p.m., revealed the oxygen concentrator filter was dusty and dirty. Resident 35 was observed using the oxygen concentrator on May 30, 2023, at 2:10 p.m. 28 Pa. Code 201.18(b)(3) Management.