Elmwood Manor Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Nov 6, 2025

  On 10/29/25, an immediate jeopardy (IJ) situation was determined to exist the facility failed to ensure Resident #1 was free from sexual abuse and psychosocial harm from Resident #2. The incident resulted in Resident #2 raising Resident #1 shirt up and inappropriately grabbing their breast in the front lobby.On 10/29/25 at 4:45 p.m., OSDH was notified and verified the existence of the IJ situation.On 10/29/25 at 5:25 p.m., the administrator was notified of the IJ situation and was provided the IJ template. On 10/30/25 at 10:56 a.m., an acceptable plan of removal was approved by the OSDH. […]

• Immediate jeopardy, isolatedF689Nov 6, 2025

  On [DATE], an IJ situation was determined to exist when the facility failed to ensure Resident #8 was monitored and received assistance while eating in their room. The incident resulted in the death of Resident #8. Resident #8 had a care plan intervention which included assist to dine.On [DATE] at 1:00 p.m., the OSDH was notified and verified the existence of the IJ situation.On [DATE] at 1:30 p.m., the administrator was notified of the IJ situation and was provided the IJ template.On [DATE] at 10:55 a.m., an acceptable plan of removal was approved by the OSDH. […]

• Actual harm, isolatedF689Jan 23, 2026

  Based on record review and interview, the facility failed to ensure a resident did not fall from a mechanical lift during a transfer for 1 (#2) of 5 sampled residents reviewed for dependent transfers using a mechanical lift.The administrator identified 19 residents were dependent for transfers using a mechanical liftFindings:A Safe Lifting & Mechanical Lift Policy, dated 01/01/25, read in part, General Safety Rules .Use proper sling and equipment .Two trained staff required .Follow manufactures instructions.Resident #2's care plan for activities of daily living, dated 10/30/25, showed the resident required a mechanical lift for transfers.A hospital imaging report, dated 11/13/25 at 11:57 a.m., showed Resident #2 had an x-ray exam of the right knee with two views. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2026

  Based on observation, record review, and interview, the facility failed to date and label stored food in 2 of 3 freezers sampled for food storage. The DON identified 36 residents received food from the kitchen. On 07/28/26 at 10:05 a.m., a brief initial tour of the kitchen and storage area that contained two stand up refrigerator/freezers and two chest type freezers was completed. The following observations were made: a. a package containing a meat-like substance was not labeled or dated;b. a package labeled roast beef was not dated; andc. a package of vegetables was not labeled or dated. A policy titled, Food Receiving and Storage, dated 11/2022, read in part, 1. All foods stored in the refrigerator or freezer are to be covered, labeled and dated (use by date). […]

• No harm, potential for more than minimal, patternF761Nov 6, 2025

  Based on observation, record review and interview, the facility failed to ensure 1 of 1 treatment cart was locked when not in use.The corporate nurse identified 39 residents resided in the facility and had one treatment cart.Findings:On 11/03/25 at 2:39 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised with insulin pens and vials in the top drawer.On 11/03/25 at 2:40 p.m., LPN #1 was observed walking to the South end of the hallway and away from the treatment cart.On 11/06/25 at 1:29 p.m., the treatment cart was observed [NAME] of the nurse's station unlocked and unsupervised.On 11/06/25 at 1:30 p.m., LPN #2 was observed standing in dining hall out sight of the treatment cart, which was unlocked and unsupervised.A policy titled Security of… […]