Elms, The

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 25, 2024

  Based on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions to prevent pressure wound development, develop a pressure relieving care plan, and implement a physician-ordered treatment for a deep tissue injury for one of two residents (R31) reviewed for facility acquired pressure ulcers in the sample of 28. These failures resulted in R31 developing a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe. Findings include: The facility's Support Surface Guidelines policy, dated 9/2013, documents, Purpose: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing relieving devices for residents at risk for skin breakdown. Preparation: 1. […]

• No harm, potential for more than minimal, widespreadF585Jun 3, 2026

  Based on Observation, Interview and Record Review, the facility failed to ensure residents were informed of how to file a grievance and ensure that written complaints can be filled anonymously. This failure has the potential to affect all 66 residents residing in the facility.Findings include:The facility's Grievance/ Complaint policy and procedure, dated 3/25/26, documents Each resident and/or resident representative may file a grievance or complaint regarding any resident right, quality of life, or quality of care concern. The party filing the grievance may present the grievance anonymously and every effort to preserve the identity of the referring source will be attempted. The Social Services Director/ Director of Nursing are the designated coordinators of this policy. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2026

  Based on observation, interview, and record review the facility failed to label opened food items in the refrigerators. These failures have the potential to affect all 66 residents residing in the facility.Findings Include:The facility's Food Receiving and Storage policy dated 11/2022 documents, Policy statement, foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. […]

• No harm, potential for more than minimal, widespreadF801Dec 7, 2022

  Based on observation, interview and record review, the facility failed to ensure dietary workers completed a food handler training certification. This failure has the potential to affect all 62 residents who consume food in the facility. Findings Include: The facility's Preventing Foodborne Illness - Food Handling policy revised 7/2014 documents 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. […]

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  Based on observation, interview, and record review, the Facility failed to ensure contact precautions were maintained for one resident (R7) with a known MDRO (Multidrug-resistant organism). This failure had the potential to affect all 14 residents (R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66) with assistancebeing provided by the same CNAs (Certified Nursing Assitants), and failed to perform hand hygiene/don gloves according to standards of practice while administering medications for two residents (R64 and R66) of seven residents reviewed for infection control in a total sample of 40. […]