Elmwood Care Center

In the surveyor’s words

From the most serious findings on record at Elmwood Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 18, 2026

  Based on observation, interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1), when Resident 1, with a history of repeated falls, sustained another fall while ambulating (walking) on his own in the facility's hallway.This failure resulted in Resident 1's falling on the ground, sustaining a fracture (broken bone) to the right hip, and transferring to the acute care hospital for right hip surgery.During a review of Resident 1's admission Record (a record with basic information) printed on 11/3/25, the record indicated Resident 1 was admitted on the facility on 04/07/25.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an… […]

• No harm, potential for more than minimal, widespreadF812Jul 18, 2024

  45091 Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Time/Temperature Control for Safety Food (TCS; a food that requires time/temperature control for safety to limit pathogenic microorganism growth or toxin formation) was not cooled safely and there was no cooldown documentation; 4. Meat was not thawed appropriately; 5. The inside of a food storage refrigerator was not clean; 6. An industrial can opener was not maintained and clean; 7. Clean plates were handled with dirty oven mitts; 8. A food service equipment drawer was not clean; 9. […]

• No harm, potential for more than minimal, widespreadF813Jul 18, 2024

  Based on observation, interview, and facility document review, the facility failed to ensure: 1. Residents had a location to safely store perishable food brought into the facility by family/visitors; and 2. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 65 residents who took food by mouth out of a census of 68. Findings: During an interview on 7/16/24 at 2:40 p.m., Certified Nursing Assistant (CNA) 1 stated sometimes food brought in by family/visitors was stored for residents in the staff refrigerator. CNA 1 stated she thought perishable food could be stored up to 24 hours in the staff refrigerator. […]

• No harm, potential for more than minimal, patternF880Sep 18, 2025

  Based on observation, interview, and record review, the facility failed to maintain infection control practices during COVID-19 (a contagious virus that mainly affects the lungs and can range from) outbreak when:1. Multiple resident rooms housing COVID-19 positive residents were left with doors open.2. Resident 2 and Resident 3, who were COVID-19 positive, were observed outside of their isolation rooms.3. Certified Nurse Assistant (CNA) 1 who assisted Resident 3 inside the room did not have personal protective equipment (PPE, proper specialized clothing or equipment worn to protect against workplace hazards or diseases).These failures had the potential to expose staff, visitors, and other residents to COVID-19, increasing the risk of transmission and compromising the health and safety of… […]

• No harm, potential for more than minimal, patternF656Jun 6, 2025

  Based on observation, interview, and record review, the facility failed to meet the needs of five of five sampled residents (Resident 1, 2, 3, 4, and 5) when the facility did not develop and implement a comprehensive, person-centered care plan to address Resident 1, 2, 3, 4, and 5 ' s use of handheld call bells when the call light system was not operational. This failure had the potential to result in Residents 1, 2, 3, 4, and 5 not receiving appropriate care and monitoring. Findings: During a record review of Resident 1's admission Record (AR), dated 5/9/25, the admission Record indicated Resident 1 was admitted to the facility in March 2023 with diagnoses of weakness and history of falling. […]