Manor at Elfindale, The

In the surveyor’s words

From the most serious findings on record at Manor at Elfindale, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 17, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to consistently date opened foods and properly close frozen foods to prevent freezer burn; stored a measuring cup in the thickener container, and did not close the container; failed to clean the fans inside of the refrigerator; and failed to clean the deflector shield in the ice machine located in the kitchen. The facility census was 94.1. […]

• No harm, potential for more than minimal, widespreadF921Nov 17, 2025

  Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when the outside of the ice machine had drips of lime down the side, the ice machine vent had fuzzy lint present, and one knob was missing from the cook stove. The facility census was 94.1. Review showed the facility did not provide a policy regarding cleaning the ice machine. Review of the cleaning schedule for September 2025 showed the following:-The September cleaning schedules showed the night shift was to wipe down the ice machine and ice reflector guard on Fridays;-The week of 09/01/25, no staff initialed completing this task;-The week of 09/08/25, no staff initialed completing this task.Observations on 09/15/25, at 9:05 A.M., and… […]

• No harm, potential for more than minimal, widespreadF812Dec 3, 2021

  Based on observation, interview, and record review, the facility failed to maintain the ice machine in a clean manner when the ice reflector shield in the ice machine located in the kitchen had a build-up of a black substance that appeared to be mold on the ice reflector shield, failed to ensure the air cooling vent in the walk in freezer was free of lint which could blow on to food stored in the walk-in freezer, and failed to ensure two fluorescent light fixtures in the dry storage pantry had covers and one cover for a fluorescent light fixture was broken. If the light bulbs were to shatter or break, food stored in the dry pantry could be contaminated by broken glass. […]

• No harm, potential for more than minimal, patternF700Dec 3, 2021

  Based on observation, interview, and record review, the facility staff failed to document completion of measurements to ensure there were no gaps that could potentially cause injury or entrapment and failed to obtain signed consent for the use of side rails for eight residents (Resident #5, #12, #36, #65, #71, #73, #76, and #80) out of a sample selection of 18 residents. The facility census was 90. Record review of the facility's policy titled, Restrictive Device Determination Guideline, showed the following information: -Prior to the initiation of any potentially restraining device being implemented, a designated member of the nursing team, with interdisciplinary Team involvement, will complete the Pre-Restraining Evaluation and request therapy screen and/or evaluation; -Alternatives to… […]

• No harm, potential for more than minimal, isolatedF655Nov 17, 2025

  Based on record review and interview, the facility failed to complete the baseline care plans for all residents within 48 hours of admission and failed to document resident and/or representative was provided a copy of the baseline care plan when staff did not complete a full baseline care plans within 48 hours of admission for two residents (Residents #37 and #95) and failed to document representative or resident notification of the care plan for the residents. A sample of 19 residents was selected for review in a facility with a census of 94. Review showed the facility did not provide a policy related to Baseline Care Plans.1. […]