Elwood Health and Living

In the surveyor’s words

From the most serious findings on record at Elwood Health and Living, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 5, 2021

  Based on observation, interview and record review, the facility failed to provide interventions to alleviate constipation for 2 of 3 residents reviewed for bowel monitoring (Residents C and B). This deficient practice resulted in Resident C being transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Resident C's closed record was reviewed on 8/5/21 at 10:29 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/26/21, quarterly, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired, was totally dependent for transfers and toileting, and was totally incontinent of bladder and bowel. […]

• Actual harm, isolatedF689Apr 26, 2021

  Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent falls for 2 of 7 residents reviewed (Residents 256 and 6), and failed to implement personalized interventions to prevent falls for 1 of 7 residents reviewed (Resident 49). This deficient practice resulted in Resident 256 and Resident 49 each sustaining a [CONDITION(S)]. Findings include: 1. During an interview, on 4/19/21 at 12:34 p.m., Resident 256 indicated she had fallen and broken her left hip a couple weeks ago. Resident 256's clinical record was reviewed on 4/20/21 at 12:57 p.m. Diagnoses included, but were not limited to, non-displaced intertrochanteric fracture of left femur and Alzheimer's disease. […]

• Actual harm, isolatedF689Jan 7, 2021

  Based on interview and record review, the facility failed to use a shower bed correctly and failed to have two staff members assist with bathing in accordance with the resident assessment and plan of care for 1 of 3 residents reviewed for accidents (Resident B). This deficient practice resulted in Resident B sustaining a fall resulting in lacerations, sutures, skin tears and pain. Findings include: The clinical record for Resident B was reviewed on 1/7/21 at 9:09 a.m. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 6/16/20, indicated the resident was moderately cognitively impaired. She required extensive two-person assistance for transfers, hygiene, bed mobility, dressing and toileting. […]

• No harm, potential for more than minimal, widespreadF812May 12, 2023

  Based on observation, record review, and interview, the facility failed to ensure the low-temperature dishwasher was tested daily for wash temperature and sanitation levels. Of the facility's 59 residents, this deficient practice had the potential to affect 58 residents who received meals from the kitchen. Findings include: During a kitchen observation, on 5/8/2023 at 7:12 a.m., accompanied by the Dietary Manager, the sanitation log for the low-temperature dishwasher was incomplete. Only the May 1, 2023 and May 2, 2023 temperatures and sanitation levels were documented, and both were initialed by three different staff members. The Dietary Manager indicated the log was supposed to be completed three times daily, and she regularly reminded staff to keep log current. […]

• No harm, potential for more than minimal, patternF602Mar 12, 2026

  Based on observation, interview, and record review the facility failed to protect the residents' right to be free from misappropriation of property for 3 of 5 residents reviewed for drug diversion. (Residents B, C, and D) Findings include:During an interview, on 3/10/26 at 10:00 a.m., the DON and Administrator indicated they had been called early in the morning about an unusual occurrence with a shift-to-shift narcotic count. The count had been off by one pill from when the original count was done. LPN 13 indicated she thought she left a pill in a cup in the medication room. She went into the medication room and brought out a pill in a cup. […]