Elon Manor Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF561Apr 2, 2026

  Based on observations, interviews, and record review, the facility failed to promote and facilitate one (1) of one (1) resident's choice to close the room door at night for privacy and personal comfort (Resident #39); and two (2) of two (2) residents right to use electric wheelchairs to support mobility, independence, and the resident's highest practicable level of functioning (Resident #s 44 and 96). This failure caused Resident #44 frustration, anxiety, mental anguish, and self-isolation, which resulted in psychological harm.The findings include:1. […]

• No harm, potential for more than minimal, widespreadF801Dec 21, 2023

  Based on record review and interview the facility failed to ensure the Dietary Manager met the mandatory minimum qualifications for the Dietary Manager position. Findings included: Review of the Dietary Manager's qualifications revealed the Dietary Manager (DM) was not [Food Certification Service] qualified and was not certified as a dietary or food service manager. During an interview on 12/20/23 at 11:09 a.m., The Dietary Manager (DM) stated I have been working as the Dietary Supervisor for three months now. The DM stated prior to being DM, I was a cook here since 2016. The DM stated she did not have an associate degree in food service or hospitality, and was not certified in food management but was working on obtaining the [Food Certification Service] certification. […]

• No harm, potential for more than minimal, patternF880Feb 25, 2026

  Based on observation and interview, the facility failed to ensure infection control practices were followed related to: 1) staff performing hand hygiene when completing medication administration, 2) cleaning of multi-use equipment, such as blood glucose monitors and blood pressure cuffs, in between uses on residents, and 3) an uncleanable surface in one of two resident shower rooms in the one west unit. Findings included: 1. On 2/23/26 at 9:20 a.m. during medication administration observation Staff A, Registered Nurse (RN) used her fingers to place vitamin D-3, aspirin, Iron, and sodium chloride pills into a medication cup to administer to Resident #62. On 2/23/26 at approximately 9:23 a.m. […]

• No harm, potential for more than minimal, patternF924Feb 25, 2026

  Based on observations, facility record review and staff interviews, the facility failed to ensure handrails were affixed to the wall in a safe and secure manner in two floors (200 and 100) of two floors observed, during three days (2/22/2026, 2/23/2026, and 2/24/2026) of four days observed. Findings included: During a facility wide tour on 2/22/2026 at 9:15 a.m., at 2:00 p.m. and on 9/23/2026 at 8:30 a.m., the following was observed: 1. The 2nd floor hallway handrail located before the shower room was not affixed tightly to the wall. 2. The 2nd floor hallway handrail located across from the nurse station and below the mirror and clock was not affixed tightly to the wall. 3. […]

• No harm, potential for more than minimal, patternF568Feb 19, 2025

  Based on observation, record review, and interviews, the facility failed to implement an accurate and up to date system for the accounting of residents' personal funds entrusted to the facility for three (#3, #5, and #6) of three residents sampled for resident funds review. Findings included: Review of accounts records for Resident's #3, #5 and #6 showed the residents' cost of care being withdrawn from their personal funds account did not consistently match what the Medicaid Access eligibility had determined, and Social Security direct deposits for January and February 2025 were not reflected in the accounts. On 02/19/2025 at 10:23 a.m. Resident #6 was observed in her room and she agreed to an interview. […]