Elmhaven East

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the mandatory 12 hours of education was completed for Certified Nurse Aides (CNA)/Certified Medication Aides (CMA) as required.

Inspectors wroteBased on interviews, record reviews and observation, the facility staff failed to implement adequate infection control practices related to hand hygiene and sanitization of shared equipment. The facility staff also failed to implement adequate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 1 while flushing his urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag).

Inspectors wroteBased on interview, observation, and record review, the facility failed to protect the dignity of Resident (R) 16 when staff left her breasts exposed unnecessarily while proving care and did not offer or place to a cover for the exposed areas not being cared for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R) 7's psychotropic as-needed (PRN) medication had the required 14 days stop date or a specified duration with a physician documented, rationale for the extended duration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident (R) 3 with a written notification of transfer to the resident and/or his representative as soon as practicable after R3 was transferred to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise Resident (R) 6's Care Plan to reflect her current and accurate advance directives.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer or obtain an informed declination for the influenza (highly contagious viral infection) immunization for Resident (R) 21 and R12. This placed the residents at risk for complications related to influenza infections.

Inspectors wroteThe facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight consecutive hours as required. This placed the residents in the facility at risk for unsupervised nursing care and services.

Inspectors wroteThe facility had a census of 30 residents. The sample included 14 residents. Based on record review and interview, the facility failed to complete the comprehensive Minimum Data Set Assessment (MDS) for three sampled residents, Resident (R)4, R16, R26, R15, R30, and R22 when staff failed to ensure the triggered Care Area Assessments (CAA) were completed as required. This placed the residents at risk for unmet care needs and inaccurate assessments.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, when two staff members entered her room during cares. This placed the resident at risk for impaired dignity and embarrassment.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R) 10's advanced directives (a legal document in which a person specifies what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether, or not, to withhold medical intervention in the event the resident's heart stops] order). Additionally, the facility failed to ensure R10's DNR was signed by the resident. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care.

Inspectors wroteThe facility identified a census of 30 residents, with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on record review, interview, and observation, the facility failed to notify the physician when Resident (R) 8 had a weight gain in 24 hours while on a diuretic (a class of medications used to promote the formation of urine and prevent fluid accumulation). This placed R8 at risk for delayed physician involvement and treatment options.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to complete the Minimum Data Set for Resident (R) 7 within the required timeframes. This placed the resident at risk for unidenitfied care needs and inadequate plan of care.

Inspectors wroteThe facility identified a census of 30 residents. The sample included 14 residents with one sampled for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, interview, and record review, the facility failed to address catheter care on Resident (R) 83's baseline care plan. This deficient practice had the risk for adverse outcomes and complications for R83 due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including two residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to recognize, assess, and implement interventions consistent with Resident (R)26's current level and/or mode of assistance required for transfers. This placed the resident at risk for injury and further ADL decline.

Inspectors wroteThe facility reported a census of 30 residents with 14 residents sampled, including four residents reviewed for positioning and range of motion (ROM). Based on observation, interview and record review, the facility failed to perform restorative cares for Residents (R)4, R26, and R16 and failed to properly position R4 while in her Geri-chair (a specialized wheelchair).

Inspectors wroteThe facility reported a census of 30 residents with 14 residents selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to properly inform families of the risks and benefits associated with psychotropic (alters mood or thoughts) medications for Resident (R) 8 and R7. It also failed to properly monitor for adverse reactions and behaviors related to an antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality) for R8. These deficient practices placed the affected residents at risk for adverse effects associated with the use of psychotropic medications.

Inspectors wroteThe facility reported a census of 30 residents. The sample included 14 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement adequate and acceptable infection control practices for Resident (R) 15 whose oxygen tubing was allowed to drag the floor as he wheeled himself through the facility. This deficient practice placed the resident at risk of infections.

Inspectors wroteFindings included: - Review of the facility's Daily Staffing Sheets, for the past 30 days, revealed the actual hours worked had not been completed on the daily staffing sheets. On 04/23/25 at 08:17 AM, Administrative Nurse E stated she was unaware the daily staff postings needed to include the actual hours worked. The facility policy for Posting Direct Care Daily Staffing Numbers, revised July 2016, included: The facility shall post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents, including the actual time worked during that shift for each category.

Inspectors wrote- The Physician Order Sheet (POS), dated 07/03/23, documented Resident (R)20 had a diagnosis of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required total assistance of two staff for bed mobility, transfers, and dressing. He had impairment in range of motion (ROM) to his bilateral (both sides) lower extremities. The resident did not receive restorative care during the assessment period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/05/23, documented the resident required extensive to total assistance of one to two staff for most ADLs. [...]

Inspectors wroteThe facility reported a census of 35 residents with 14 residents sampled, that included six residents reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide restorative services to maintain, improve, or prevent avoidable decline in ROM and mobility for four Residents (R)1, R 11, R 20, and R 28, of the six residents reviewed.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review. Based on interview and record review, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment Section V Care Area Assessment Summary (CAA) for Resident (R)19 and R 10 to include an analysis and rationale for care planning decisions. This placed these residents at risk for not accurately reflecting each resident's status and needs to develop an individualized comprehensive plan of care.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to complete a significant change comprehensive assessment for one selected Resident (R)19, when this resident discharged from hospice services, as required to ensure accurate needed cares provided.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review, which included three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure staff provided increased nutritional support, alternative pressure relieving measures, and sanitary dressing changes for one Resident (R)5 following surgical debridement (removal of dead tissue) of her stage four pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough [dead tissue, usually cream or yellow in color] or eschar [dead tissue] may be present on some parts of the wound bed. Often includes undermining and tunneling).

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review, that included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure staff provided safe wheelchair transport to prevent accidents for one Resident (R)28, of the three selected residents.

Inspectors wroteThe facility reported a census of 35 residents with six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility consulting pharmacist failed to identify the facility failure to monitor the effectiveness of warfarin (a blood thinner medication) for one Resident (R)10, of the six reviewed residents.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff monitored the warfarin (a blood thinner medication) for one Resident (R)10, to prevent adverse reactions.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents selected for review, that included six residents for review of unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for insulin (a medication used to lower blood sugar) administration for one Resident (R)2.

Inspectors wroteThe facility reported a census of 35 residents with 14 residents sampled, that included two residents reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure to provide appropriate urinary catheter care to prevent urinary tract infections (UTI) for the two reviewed dependent Residents, (R)8 and R 20.