Elmwood Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 8, 2022

  Based on record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to prevent new pressure ulcers from developing for 1 of 4 sample residents reviewed who is at risk for developing pressure ulcers, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 6/6/2022 revealed this resident has a sacral wound which is almost completely down to the bone. […]

• No harm, potential for more than minimal, widespreadF941Sep 5, 2025

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide the mandatory effective communication training for 7 of 7 direct care staff members, Staff K, L, M, N, O, P, and Q regarding Resident ID #63 who only speaks Cantonese (a traditional variety of Chinese language originating from the city of [NAME]). Findings are as follows:During a surveyor interview on 9/2/2025 at approximately 10:20 AM with Resident ID #63, s/he was unable to communicate in English.Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed that his/her preferred language is Chinese.Record review of his/her care plan revealed that s/he does not speak the dominant language of the facility and speaks Cantonese.Record review of the employee… […]

• No harm, potential for more than minimal, widespreadF726Dec 16, 2024

  Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 1 of 1 staff reviewed, Registered Nurse, Staff A . […]

• No harm, potential for more than minimal, widespreadF888Aug 5, 2022

  Based on record review and staff interview it has been determined that the facility failed to have a tracking mechanism that identified each staff's role, assigned work area, and how they interact with residents for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Findings are as follows: Review of the facility's Staff COVID-19 vaccination tracking document revealed tracking for direct hire staff. […]

• No harm, potential for more than minimal, patternF552Jan 14, 2026

  Based on clinical record review and staff interview, the facility failed to inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering and administration of an antipsychotic medication for 1 of 1 resident reviewed, for the use of Zyprexa (an atypical antipsychotic medication), Resident ID #2.Findings are as follows:Review of the facility policy titled, Medication Administration Safety, Psychotropic Medications and New Medication Orders dated 4/28/2025 states in part, .Any and all psychotropic medications require resident or representative consent. […]