Elms, the

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure residents were informed of how to file a grievance and ensure that written complaints can be filled anonymously. This failure has the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to label opened food items in the refrigerators. These failures have the potential to affect all 66 residents residing in the facility. Findings Include:The facility's Food Receiving and Storage policy dated 11/2022 documents, Policy statement, foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. The facility's Refrigerators and Freezers policy dated 11/2022 documents, Policy statement, this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. [...]

Inspectors wroteBased on record review and interview the facility failed to prevent resident-to-resident verbal abuse for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT) conducted and documented a comprehensive evaluation prior to the initiation and dosage increase of an antipsychotic medication to determine whether a resident was experiencing an underlying condition contributing to their symptoms, failed to document behaviors and diagnoses to support the use of an antipsychotic medication, failed to ensure a consistent and clinically documented diagnosis was used to justify the use of an anti-psychotic medication, failed to complete psychotropic assessments, and failed to follow physician's orders related to an antipsychotic medication for two of three residents (R7 and R16) reviewed for antipsychotic medication use with diagnoses of dementia in a sample of 30.

Inspectors wroteBased on record review and interview, the facility failed to report resident-to-resident verbal abuse to the administrator and state agency for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.

Inspectors wroteBased on record review and interview, the facility failed to investigate and submit a final report to the state agency regarding resident-to-resident verbal abuse for two of two residents (R16 and R76) reviewed for abuse in the sample of 30.

Inspectors wroteBased on record review and interview the facility failed to perform a significant change comprehensive assessment after residents exhibited an increase in behaviors, were diagnosed with new psychiatric conditions, and were prescribed new ant-psychotics medications for two of two residents (R3 and R16) reviewed for signification change in condition in the sample of 30. The Centers for Medicare and Medicaid Services (CMS) (Resident Assessment Instrument) RAI 3.0 Manual dated 10/2025 documents a resident with MI or ID/DD must have a Resident Review conducted when there is a significant change in the resident's physical or mental condition. [...]

Inspectors wroteBased on record review and interview the facility failed to accurately code the MDS (Minimum Data Set) Assessments for two of 17 residents (R3 and R4) reviewed for MDS Accuracy in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to notify the state mental health authority once a resident experienced an increase in behaviors, was diagnosed with a new psychiatric condition, and was prescribed a new anti-psychotic medication for one of two residents (R16) reviewed for a significant change in condition in the sample of 30. R16's MDS (Minimum Data Set) dated 10/15/25 documents R16 does not receive anti-psychotic medication. R16's Behavior Note dated 12/4/25 at 10:58 AM documents, (R16) is very angry and anxious this am (morning). (R16) states that she does not want to move to south. It is not fair that I have to leave my home. Attempted to talk with resident but she just walks away. R16's Behavior Note dated 12/4/25 at 8:23 AM documents, (R16) is yelling at roommate. (R16) states that it is not fair that (R16) has to move to south hall. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to follow their policy/procedure for incontinence care, complete hand hygiene and glove changes during incontinence care for one of two residents (R41) reviewed for incontinence care in the sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to replace oxygen tubing/nebulizer masks weekly or store/label oxygen tubing/nebulizer masks correctly for three of six residents (R8, R21, R50) reviewed for oxygen in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions/EBP during direct cares for one of three residents (R41) reviewed for infection control in the sample of 30.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and post a notice that survey results are available for review. This failure has the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on Observation and Interview, the facility failed to ensure the daily resident census and facility staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on interview and record review the Facility delayed immunotherapy oncology services for a Medicare Part A payor source causing missed scheduled appointments for one of three Residents (R1) reviewed with a Medicare Part A payor source in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure contact precautions were maintained for one resident (R7) with a known MDRO (Multidrug-resistant organism). This failure had the potential to affect all 14 residents (R1, R6, R7, R8, R12, R14, R18, R32, R35, R48, R54, R60, R65 and R66) with assistancebeing provided by the same CNAs (Certified Nursing Assitants), and failed to perform hand hygiene/don gloves according to standards of practice while administering medications for two residents (R64 and R66) of seven residents reviewed for infection control in a total sample of 40. Findings Include: The Facility's undated Isolation-Categories of Transmission-Based Precautions Policy documents, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify an appropriate indication for use of an antipsychotic medication, and failed to identify target behaviors for two residents (R30, R40) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions to prevent pressure wound development, develop a pressure relieving care plan, and implement a physician-ordered treatment for a deep tissue injury for one of two residents (R31) reviewed for facility acquired pressure ulcers in the sample of 28. These failures resulted in R31 developing a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess, monitor, and document ongoing status of a venous stasis ulcer for one of one residents (R18) reviewed for non-pressure wounds in the sample of 28. Findings Include: The facility's Wound Care policy (dated 2010) documents the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. This policy also documents, Documentation- The following information should be recorded in the resident's medical record: The type of wound care given; The date and time the wound care was given; The name and title of the individual performing the wound care; Any change in the resident's condition; All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; Any problems or complaints made by the resident during the procedure; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a gait belt was in place during a transfer of a resident who requires staff assistance with transfers for one of four residents (R29) reviewed for ADL (activities of daily living) assistance in the sample of 28. Findings Include: The facility's Transfer Belt Policy, dated 12/2013, documents, Transfer belts are to be applied to any resident that requires hands on assist unless the careplan gives a reason not to use the belt. R29's current care plan, dated 3/29/24, documents, (R29) needs assistance with ADL's (Activities of Daily Living) and mobility related to decreased mobility, poor cognition, poor activity tolerance,behaviors, and balance deficits. I have ROM (Range of Motion) deficits bilateral upper and bilateral lower extremities. I also have dysphagia (difficulty swallowing). Restorative: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address a significant weight loss, develop, and implement interventions to prevent further weight loss, and to ensure dietitian assessment with significant weight loss for one of one resident (R9) reviewed for weight loss in the sample of 28.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide ongoing communication with the dialysis center and ensure a care plan was implemented regarding monitoring, care and emergency management of a dialysis access site for one of one (R46) resident reviewed for dialysis in the sample of 28. Findings Include: R46's current medical record documents R46's diagnoses to include: End Stage Renal Disease and Dependence on Renal Dialysis. On 04/23/24 at 09:40 AM, R46 was sitting in a wheelchair in her room watching television. R46 stated she attends hemodialysis at a local dialysis facility on Mondays, Wednesdays, and Fridays. R46 pointed to her dialysis access site located in her left upper arm and stated that dialysis staff are the individuals that monitor and care for her access site. R46 stated the staff nurses at the facility, Don't really mess with it at all. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and monitor residents target behaviors with the use of an antipsychotic medication for two of two residents (R8, R52) reviewed for antipsychotic medications in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication to lower blood pressure was accurately administered according to the Physician's Order for one of five residents (R1) reviewed for medication administration in the sample of 28. Findings Include: The facility's Medication Administration policy, dated 4/2019, documents, It is the policy of (the facility) to ensure that medications are administered safely and accurately to residents for whom they are prescribed. The facility's Medications Errors policy, dated 10/2017, documents, It is the policy of (the facility) that all medications be given as ordered by the resident's physician. The resident will be closely monitored for negative effects. R1's Physician Order Sheet, dated 4/24/24, documents R1 has an order for, Labetalol Hydrochloride oral tablet 200 mg (milligrams): [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply gloves prior to providing high-contact care and ensure appropriate isolation precautions were in place for one of four residents (R19) reviewed for infection control practices in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of low blood pressure for one of three residents (R3) reviewed for falls in a sample of three. Findings Include: The Facility's undated Change in Resident's Condition or Status documents, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident/s medical. Mental condition and/or status. The policy documents The nurse will notify the resident's attending physician or physician on call when there has been a (an) d.) significant change in the resident's physical/emotional/mental condition and specific instruction to notify the physician of changes in the resident's condition. [...]