Elmbrook Home

In the surveyor’s words

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

• Actual harm, isolatedF684Feb 13, 2026

  Based on record review and interview, the facility failed to ensure the proper repositioning of a dependent resident was performed for 1 (#3) of 3 sampled residents reviewed for safe transfers.The regional nurse consultant identified 65 residents resided in the facility. Findings:On 02/11/26 at 12:00 p.m., Res #3 was observed sitting in their recliner with their feet elevated. A bandage and dark purple bruising were observed on their right forearm.On 02/11/26 at 1:24 p.m., Res #3 was observed sitting in their recliner and watching television. […]

• No harm, potential for more than minimal, patternF644Jan 16, 2025

  Based on record review and interview, the facility failed to refer a resident with newly diagnosed mental illness diagnoses to the OHCA for a level II PASARR evaluation for one (#40) of two sampled residents reviewed for PASARR. The administrator reported 67 residents resided in the facility. Findings: Resident #40 was admitted to the facility on [DATE]. A level I PASARR, dated 02/09/21, documented no level II PASARR was required. Resident #40 had diagnoses added since admission which included mood disorder, date diagnosed [DATE], and unspecified psychosis, date diagnosed [DATE]. On 01/14/25 at 4:33 p.m., the regional nurse consultant reported the resident's PASARR had not been reevaluated after the new mental illness diagnoses. […]

• No harm, potential for more than minimal, patternF684Jan 16, 2025

  Based on observation, record review, and interview, the facility failed to transcribe a physician order and schedule a mammography in a timely manner as requested for one (#41) of one resident reviewed for a physician ordered mammography. The administrator reported 67 residents resided in the facility. Findings: A Transportation, Diagnostic Services policy, dated December 2008, read in parts, Should it become necessary for the facility to provide transportation, the Social Service Designee will be responsible for arranging the transportation through the business office .A member of the Nursing Staff, or Social Services, will accompany the resident to the diagnostic center when the resident's family is not available. […]

• No harm, potential for more than minimal, patternF689Jan 16, 2025

  Based on observation, record review, and interview, the facility failed to follow their policy to ensure a safe environment for smokers for two (#45 and #55) of two residents sampled for accident hazards. The administrator reported 10 residents who smoked, seven of which were unsupervised smokers. Findings: A Smoking Policy - Residents policy, dated July 2017, read in parts, A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff .Residents shall have the supervision of a staff member, family member, visitor or volunteer worker at all times while smoking .Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under supervision. 1. […]

• No harm, potential for more than minimal, patternF880Jan 16, 2025

  Based on observation, record review, and interview, the facility failed to ensure proper disposal of blood contaminated glucometer strips for one (#52) of two sampled residents reviewed for finger stick blood sugar levels. The DON reported 25 residents received finger stick blood sugar levels. Findings: A policy for Blood Sampling, dated 09/14/14, read in parts, The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees .Equipment and supplies, sharps container .Discard lancet and platform into the sharps container. […]