Elms Retirement Village Inc

In the surveyor’s words

From the most serious findings on record at Elms Retirement Village Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF570Aug 26, 2021

  Based on review of the surety bond, trial balance funds sheet and staff interview the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This affected 26 residents who currently had a resident funds account with the facility. The facility census was 39. Findings include: Review of this facility's surety bond revealed it was in the amount of $35,000.00. Review of the resident trial balance funds documented the total money in the resident funds account totaled $46,104.68. Interview on 08/25/21 at 10:30 A.M. the Administrator verified the amount of monies in the resident funds account exceeded the amount of the surety bond.

• No harm, potential for more than minimal, isolatedF578Aug 6, 2026

  Based on medical record review, staff interview, and policy review, the facility failed to ensure advanced directives were consistent in the Electronic Medical Record (EMR) and the paper chart. This affected two residents (#19 and #45) of four residents reviewed for advanced directives. The facility census was 49. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/19/24. Diagnoses included chronic obstructive pulmonary disease, osteoarthritis, atrial fibrillation, vitamin D deficiency, hyperlipidemia, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. […]

• No harm, potential for more than minimal, isolatedF600Jul 8, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of facility self-reported incident (SRI) including investigation, review of staff timecard, observation, staff and resident interviews, and policy review, the facility failed to ensure a resident was free from neglect when Resident #37 was not provided any activities of daily living (ADL) for a twelve-hour shift. This affected one (#37) of three residents reviewed for abuse and neglect. […]

• No harm, potential for more than minimal, isolatedF580May 2, 2025

  Based on review of the medical record, review of the facility investigation, interview with the staff, and review of facility policy and procedure, the facility failed to ensure the legal representative, physician and Resident #50 were notified of a medication error for Resident #50. This affected one resident (Resident #50) of three reviewed for medication errors. Findings included: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, stage four sacral wound, stage four right buttock wound, osteomyelitis, severe protein calorie malnutrition, anxiety disorder, depression, and cachexia. […]

• No harm, potential for more than minimal, isolatedF760May 2, 2025

  Based on review of the medical record, review of the facility investigation, interview with the staff, and review of facility policy and procedure, the facility failed to ensure Resident #50 was free of significant medication errors. This affected one resident (Resident #50) of three reviewed for medication errors. Findings included: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, stage four sacral wound, stage four right buttock wound, osteomyelitis, severe protein calorie malnutrition, anxiety disorder, depression, and cachexia. She had a Power of Attorney (POA) and was discharged home on [DATE]. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 had intact cognition. […]