The Elms Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 25, 2024

  Based on observation, interview, and record review, it was determined that the facility failed to assess a resident after implementing a new device for safety resulting in a fall with serious injury for 1 out of 4 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier is #26). Findings include: Review on 1/24/24 of Resident #26's progress notes revealed the following: Resident received [pronoun omitted] new wheelchair on 11/1/23 from [company name omitted]. this new wheelchair does not have a seatbelt connected and therapy stated that [company name omitted] will be back 1-2 weeks . (dated 11/2/23 at 9:56 a.m.) Resident noted to be sliding down or slouching down in wheelchair seat frequently throughout the shift. […]

• No harm, potential for more than minimal, widespreadF880Jan 10, 2025

  Based on interview and record review, it was determined that the facility failed to implement and review, at least annually, the facility's water management plan that has the potential to effect the facility census of 46 residents who resided at the facility. Findings include: Review on 1/8/25 of the facility's water management plan revealed the following: 1. The last review date was dated June 2023, which is 18 months of when the plan was last reviewed. 2. The water management plan committee consisted of the Maintenance Supervisor, Director of Nursing, and the Administrator. There was no Infection Preventionist included in the committee. […]

• No harm, potential for more than minimal, widespreadF725Jan 25, 2024

  Based on interview, observation, and record review, it was determined that the facility failed to ensure sufficient staffing to ensure that each resident attained or maintained the highest practicable physical, mental, and psychosocial well-being. Facility census of 52 residents (Resident Identifier #153). Findings include: Interview on 1/23/24 at approximately 9:00 a.m. with Staff C (Licensed Practical Nurse) revealed that the facility had 2 LNAs (Licensed Nursing Assistants) on for the day shift a few times over the last few weeks and most days there were 3 to 4 LNAs on the day shift. […]

• No harm, potential for more than minimal, patternF679Dec 2, 2021

  Based on observation, interview, record review and policy, it was determined that the facility failed to ensure that facility-sponsored group and individualized activities were provided to support residents based on the resident's choices and care plan for 3 residents out of 4 residents reviewed for activities out of a final sample size of 21 residents and 6 residents out of 15 residents in resident council. (Resident identifiers are #3, #5, #17, #19, #24, #30, #35, and #38) Findings include: Resident #5 Observation on 11/30/21 at approximately 9:50 a.m. in Resident #5's room revealed that Resident #5 was awake in bed with the television and radio off. Interview on 12/1/21 at 9:35 a.m. […]

• No harm, potential for more than minimal, isolatedF635May 27, 2026

  Based on interview and record review, the facility failed to ensure physician orders at admission were accurate for 1 of 4 residents reviewed for admission orders (Resident identifier is #4).Findings include:Review on 5/27/26 of Resident #4's progress note written by Staff A (Director of Nursing) dated 5/17/26 [name omitted] was discharged from [hospital omitted] on 5/9/26. [pronoun omitted] discharge summary was not reviewed with the physician on call.Medications had changed and [pronoun omitted] received the wrong dose of some [medications] and omission of others [medications] from 5/9/26 - 5/13/26.Review on 5/27/26 of Resident #4's Hospital Discharge summary dated [DATE] revealed a change in Carvedilol dose from 25mg to 12.5mg twice a day, a new order for Voltaren 1% gel topically to… […]