Elm Crest Retirement Community

Inspectors wroteBased on clinical record review, facility investigation file review, resident and staff interviews, and policy review the facility staff failed to follow the facility's fall policy and protocol to notify the charge nurse in order to complete an assessment in a timely manner and begin interventions after a resident had a fall for one of three residents reviewed for injuries of unknown origin and nursing supervision (Resident #1). The facility reported a census of 41 residents. The facility corrected the deficient practice per past noncompliance on 2/17/26 through the following actions: *The facility DON and Administrator began an investigation when the bruises were discovered on Resident #1 on 2/4/26.*The facility sent Resident #1 to the Emergency Department (ED) on 2/4/26 for evaluation. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were served meals according to the residents' specific needs for 5 of 46 residents reviewed. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to maintain a clean kitchen environment. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, family and staff interviews, clinical record review and policy review, the facility failed to ensure that staff used safe transferring techniques for 1 of 4 residents reviewed. Resident #4 had many falls and required 2 staff assistance. On 9/12/25 he had another fall while being transferred from the toilet to the wheel chair with just one staff. The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, observation, facility document review, staff interviews and facility policy review, the facility failed to use safe transfer techniques for 1 of 3 residents. Resident #37 had fell in the bathroom and sustained bruising and a skin tear after staff assisted him without the use of a gait belt or proper footwear. The facility also failed to implement new interventions with repeat falls to reduce the risk for Resident #37. The facility reported a census of 43 residents.

Inspectors wroteBased on observation, facility record review, staff interviews and policy review the facility failed to follow proper sanitation to prevent the spread of illness according to professional standards by serving residents on dishes that had not been rinsed in the hot water dish machine at an appropriate temperature to prevent the spread of illness. The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 3 of 3 residents (Resident #9, #33 and #21). The facility reported a census of 43 residents.

Inspectors wroteBased on staff interviews, clinical record review, facility document review and policy review the facility failed to ensure that all residents were treated with dignity and respect for 1 of 14 residents reviewed. A staff member was demanding, forceful and demeaning to Resident #96 when she became restless and tried to get out of her chair unassisted. The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment during the required timeline for 1 of 14 residents reviewed (Resident #35). The facility census was 43.

Inspectors wroteBased on electronic health record review, document review, policy review and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for a diagnosis of methicillin-resistant staphylococcus aureus (MRSA) and or enhanced barrier precautions (EBP) related to the diagnosis of a multidrug-resistant organism (MDRO) for 1 of 5 residents reviewed (Resident #22). The facility reported a census of 43 residents.

Inspectors wroteBased on clinical document review, resident interview, staff interview, and policy review the facility failed to provide services to increase mobility or prevent a loss in mobility for 1 of 2 residents (Resident #12) reviewed. The facility reported a census of 43 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed, requiring the use of a nebulizer (Resident #6). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to review and revise the care plan to reflect the resident's current status for 4 of 4 residents reviewed (Resident #1, #2, #3, #4). The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not completing assessments on individuals who sustained ground level falls with major injury for 2 of 4 residents (Resident #1 and #3) reviewed and failed to implement facility protocol by transferring without a full body lift after a fall for Resident #1. The facility reported a census of 44 residents.

Inspectors wroteBased on observation, interview, and service record review the facility failed to keep the ice machine clean and sanitary. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure that staff practiced recommended hand hygiene to prevent the spread of pathogens during the meal service. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, interview, and operator manual review the facility failed to ensure that staff used safe transfer techniques for 1 of 3 residents reviewed (Resident #22). Resident #22 required the use of a sit to stand mechanical lift for transfers. As the staff transferred Resident #22, they failed to tighten the belt around her torso before moving her from the wheel chair to the bed.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to dispose of narcotic medications after the doctor gave an order to discontinue them for two of two residents reviewed (Residents #91 and #36). 1. Resident #91 passed away on 8/20/23. During the survey in October 2023, discovered some of her medications still in the refrigerator. 2. Resident #36 had an order for tramadol to use for pain as needed that got discontinued on 6/1/23. During the survey in October 2023, the narcotic drawer still contained 60 tablets of tramadol. The facility reported a census of 40 residents.