Elmwood Care Center

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who required intermittent self-catheterization (inserting a thin, flexible tube called a catheter through the urethra into the bladder to drain urine, typically done several times a day to prevent urinary tract infections and kidney damage), was provided the necessary physician-ordered catheter supplies to support Resident 1's ability to perform activities of daily living. This failure had the potential to result in Resident 1's urinary retention (inability to completely or partially empty the bladder), infection and discomfort during procedure.

Inspectors wroteBased on interviews and record review, the facility failed to administer medication as ordered by their physician for one of three sampled residents (Resident 1), when the facility did not administer Resident 1's physician ordered dose of insulin (a hormone needed to move sugar from blood into cells for energy). This failure had the potential to jeopardize Resident 1's health and safety. During a review of Resident 1's admission Record, printed 4/16/26, the Record indicated Resident 1 was admitted to the facility in February 2026 with a diagnosis of Type 1 Diabetes Mellitus (a chronic condition where the body's immune system attacks and destroys insulin producing cells in the pancreas, requiring daily insulin treatment to prevent high blood sugar) . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1), when Resident 1, with a history of repeated falls, sustained another fall while ambulating (walking) on his own in the facility's hallway. This failure resulted in Resident 1's falling on the ground, sustaining a fracture (broken bone) to the right hip, and transferring to the acute care hospital for right hip surgery. During a review of Resident 1's admission Record (a record with basic information) printed on 11/3/25, the record indicated Resident 1 was admitted on the facility on 04/07/25. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the facility front entry door would lock. This failure had the potential to result in a significant security and safety issue potentially endangering the residents, staff and visitors. During an observation on 9/18/25 at 9:57 a.m. the front door of the facility was ajar and unlocked. The survey team was able to access the facility without staff being aware. There was no audible alarm to signify that someone had entered the facility, and the reception area was unattended. During a phone interview with the facility Administrator and Maintenance Supervisor on 9/19/25 at 12:20 p.m. the Maintenance Supervisor and Administrator both stated they did not know the entry door did not lock. During a concurrent observation and interview on 9/19/25 at 12:30 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that during a facility COVID outbreak:All staff wore a facemask. This failure had the potential to result in transmission of the respiratory COVID virus. Staff actively monitored visitors entering the facility for hand hygiene, temperature checks, and assessment of respiratory infections(fever, cough, shortness of breath and sore throat). This failure had the potential to result in transmission of the COVID -19 virus.1. During an observation and interview on 9/19/25 at 10:45 a.m. Maintenance Worker (MW)1 was observed walking through the facility not wearing a mask and exited down the stairwell on station 2. With an interpreter MW 1 stated he was not wearing a face mask and did not stop when surveyor wanted to interview him. MW1 stated he knew the facility had a COVID outbreak and he did not have a mask. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report of suspected allegations of abuse for two of two sampled residents (Resident 1 and Resident 2) within the required 24-hour time frames when:Resident 1 who had a bruise of unknown origin on the right upper arm was not reported to the State Survey Agency and Long-Term Care Ombudsman (LTCO, resident advocate) within the reporting time frame. Resident 2's suspected allegation of verbal abuse from an employee was not reported to the LTCO. These failures had a potential to delay protective investigations and placed Resident 1 and Resident 2 at risk for ongoing unaddressed abuse and potential harm. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a thorough investigation was conducted and completed within five working days following an allegation of abuse for one sampled resident (Resident 2) and the facility did not not have an investigation summary documenting the findings and result of the investigation. This failure had the potential for the allegation of abuse to remain uninvestigated and placed Resident 2 at risk for ongoing abuse due to the absence of protective interventions and corrective actions. During a record review of Resident 2's admission Record (AR), printed on 9/29/25, the AR indicated Resident 2 was admitted to the facility in December 2024 with diagnoses of cellulitis (skin infection) of abdominal wall and ileostomy status (presence of an opening in the stomach where waste comes out into a bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices during COVID-19 (a contagious virus that mainly affects the lungs and can range from) outbreak when:1. Multiple resident rooms housing COVID-19 positive residents were left with doors open.2. Resident 2 and Resident 3, who were COVID-19 positive, were observed outside of their isolation rooms.3. Certified Nurse Assistant (CNA) 1 who assisted Resident 3 inside the room did not have personal protective equipment (PPE, proper specialized clothing or equipment worn to protect against workplace hazards or diseases). These failures had the potential to expose staff, visitors, and other residents to COVID-19, increasing the risk of transmission and compromising the health and safety of residents and staff during an active outbreak. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the needs of five of five sampled residents (Resident 1, 2, 3, 4, and 5) when the facility did not develop and implement a comprehensive, person-centered care plan to address Resident 1, 2, 3, 4, and 5 ' s use of handheld call bells when the call light system was not operational. This failure had the potential to result in Residents 1, 2, 3, 4, and 5 not receiving appropriate care and monitoring.

Inspectors wroteBased on observation, interview, and record review the facility nursing staff did not perform hand hygiene and infection control prevention to industry standard when handling waste disposal after caring for two residents (Residents 1 and 2). This failure had the potential to cause the spread of infection, which could result in hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Time/Temperature Control for Safety Food (TCS; a food that requires time/temperature control for safety to limit pathogenic microorganism growth or toxin formation) was not cooled safely and there was no cooldown documentation; 4. Meat was not thawed appropriately; 5. The inside of a food storage refrigerator was not clean; 6. An industrial can opener was not maintained and clean; 7. Clean plates were handled with dirty oven mitts; 8. A food service equipment drawer was not clean; 9. The ceiling above a food preparation area was not clean; 10. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure: 1. Residents had a location to safely store perishable food brought into the facility by family/visitors; and 2. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 65 residents who took food by mouth out of a census of 68.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 6 residents on Renal diets (diet that promotes kidney health) and Renal Consistent Carbohydrate (CCHO; a diet typically prescribed to control blood sugar) out of 65 residents who received food from the kitchen. This failure had the potential to result in providing residents on a Renal diet and Renal CCHO diets with an inadequate and/or a harmful amount of nutrients, further compromising residents' medical status.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the appropriate food texture for mechanical soft diets. This deficient practice had the potential to cause difficulty with eating, chewing, and/or swallowing leading to an increased risk of choking for 10 of 10 residents who received prescribed mechanical soft diets.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to fortify resident food according to physician orders. This failure had the potential to result in decreased calorie intake for two (Residents 9 and 14) out of seven residents who had physician prescribed fortified diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was functioning for 13 of 68 sampled residents (Resident 32, 168, 40, 174, 26, 51, 20, 31, 41, 2, 4, 5, and 53). This deficient practice had the potential to result in the delay of care and services.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable, temperature-controlled environment for one of six residents (Resident 319) when Resident 319's window was in a fixed open position and found to be non-functional due to a missing crank. This failure prevented Resident 319 from opening or closing the window at the resident's discretion to control the room's temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate did not exceed five percent. There were four medication errors out of 26 opportunities for errors, which resulted in an error rate of 15.38 percent (%). 1. For Resident 39, Licensed Vocational Nurse (LVN) 2 administered insulin (a medication that helps people control their blood sugar) that was expired for 13 days. 2. For Resident 220, LVN 3 administered Senna (a medication used to relieve constipation) . and Divalproex (a medication used to treat seizures) 2hrs (hours) over their appropriate scheduled timeframe, and Levetiracetam (a drug used to treat seizures) 3hrs over it's appropriate scheduled timeframe. These failures had the potential to jeopardize resident 39 and 220's health due to unsafe medication administration practices not being followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for two of two sampled residents (Residents 5 and 39), when the following was observed: 1. Licensed Vocational Nurse 3 (LVN) did not clean and sanitize the glucose monitor (a device for measuring the concentration of glucose in the blood) in between finger stick blood sugar tests (a test that measures blood glucose levels by pricking a fingertip with a lancet and applying a drop of blood to a test strip in a glucose monitor) for resident 5 and 39. 2. LVN 3 disposed Resident 5 and 39's contaminated blood sugar lancets in residents 5 and 39's trash cans. 3. LVN 3 did not perform hand hygiene in between resident 5 and 39's finger stick blood sugar tests. These failures placed Residents 5 and 39 at risk for injury, cross contamination, and infection.

Inspectors wroteBased on observation and interview, the facility had 34 resident (Rt) rooms (100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 116, 118, 200, 202, 204, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 225) with multiple beds that provided less than 80 square feet per (sq.ft) resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices to prevent spread of infection when: 1a. The glucometer (device used to measure the blood sugar level) was not sanitized per manufacturer specifications in-between resident care use on two residents (Resident 28 and Resident 10) out of a census of 63. 1b. The Blood Pressure device (or BP device, included a cuff that wraps around the arm, a rubber squeeze bulb, and a gauge that measured the blood pressure flow in the body), medication tray (a small shared tray used to carry the medication to resident's room) and the Pulse-oximeter device ( or Pulse-ox, a device placed on fingertip to measure blood oxygen level) were not sanitized in-between resident care use on two residents (Resident 258 and Resident 214) out of a census of 63. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care with dignity for one of three sampled residents (Resident 8) when two licensed nurses did not provide privacy for Resident 8 during nursing care. This deficient practice resulted in not ensuring resident 8's rights to be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure self-administered medications kept at bedside were reviewed and approved by medical doctor in one resident (Resident 260) out of 21 sampled residents. This failure could result in unsafe medication use in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preference for one of one sampled resident (Resident 15) was honored, when the facility served food Resident 15 disliked. This deficient practice had a negative impact on Resident 15's overall health when Resident 15 did not eat his food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure range of motion (ROM) exercises were provided according to the physician's order, for three of three sampled residents (Resident 33, 41, and 29) with limited ROM. This failure had the potential to result in decline in the Resident 33, Resident 41, and Resident 29's ROM and functioning.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe and accountable medication handling with census of 63 when: 1. The unused or discontinued medication were disposed of without double signature of the two licensed staff. 2. Narcotic medication (medications with high potential for abuse or unlawful use) removal from the Controlled Drug Record (or CDR, a paper record that tracked narcotic medication use) were not documented in the Medication Administration Record (or MAR- a legal document for medications given to a residents) when given to the Resident 9 and Resident 55. 3. Medication orders in the MAR did not have monitoring parameter for vital signs such as Blood Pressure (or BP, the force of the blood against the artery walls), or heart rate (same as heart beat) in Resident 30, Resident 31. 4. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure one resident (Resident 30) out of 21 sampled residents, was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when the indication for use was not addressed by medical providers consistently. The failure had potential for unsafe medication use in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5% during the medication administration observation with census of 63. The facility had a total of nine errors out of 51 opportunities which resulted in a facility wide medication error rate of 17.65 % (% or percent, a fraction of the 100th). Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. These failures may result in unsafe medications use and not following the doctor's orders.

Inspectors wroteBased on interview, and record review the facility failed to ensure safe and accurate transcription of doctor's order in the electronic medical record in one out of 21 sampled residents (Resident 41), when a high risk injectable (a shot) medication called insulin (medication given as a shot under the skin to treat blood sugar disease) was transcribed with a dangerous dosage and duplicate orders were transcribed in the Medication Administration Record (or MAR, a legal document showing doctor's order, how and how much medicine to give). This failure had potential to cause adverse health outcomes.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe medication storage practices in the main medication room (a locked room used to store medications and supplies) and one out of three medication carts (a mobile cart stored medication and supplies for immediate use) when: 1. Expired (outdated) medication were stored in the active storage areas in the medication room and the refrigerator. 2. Unlabeled prescription medications were stored in the active storage areas in the medication room and the medication cart. 3. Undated multidose containers were stored in active storage areas in the refrigerator, medication cart and medication room. 4. Discontinued medication stored in the active storage areas in the refrigerator and the medication room. These failed practices could contribute to unsafe medication use in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was free from food being stored past their use-by date and keeping the toaster clean after use as evidenced by 1. Multiple unlabeled, undated pre-made sandwiches, fruits and vegetables were stored and used by their use-by date in the kitchen refrigerator. 2. Toaster containing black debris matter This failure has the potential to cause foodborne illnesses to any resident who consumes them which can result in illness or hospitalization.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage and refuse were properly stored in dumpster when the lid of one of two dumpsters was broken and did not securely cover the bin. This failure had the potential for pest infestations and spread of diseases in the facility.

Inspectors wroteBased on observation and interview, the facility had 34 resident (Rt) rooms (100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 116, 118, 200, 202, 204, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 225) with multiple beds that provided less than 80 square feet per (sq.ft) resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions when refrigerated food items were not dated, when a scoop was stored in a food bin, a dented can was stored along with other undented cans in the dry food storage area, dirty plates were stored as clean, kitchen swamp cooler vents were unclean and dietary staff had uncovered hair. These deficient practices had the potential to place residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and record review one Registered Nurse (RN 2) failed to wash her hands according to facility guidelines for Handwashing/Hand Hygiene when performing a dressing change on one Resident's (Resident 56) pressure ulcer. This had the potential to transfer germs from RN 2's unwashed hands after cleaning Resident 56's wound to the cleansed wound, which could increase the risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interior temperature were within comfortable level when rooms [ROOM NUMBERS]'s temperature were below comfortable level. This failure had the potential to result in uncomfortable interior temperature.

Inspectors wroteBased on observation, interview and record review, for one of two sampled residents (Resident 41), facility failed to develop and implement a comprehensive care plan to address Resident 41's self-administration of an eye medication. This failure had the potential to result in improper use of eye medication.

Inspectors wroteBased on observation, interview and record review, for one of 21 sampled residents (Resident 10), the facility failed to provide nail care. This failure had the potential to result in skin infections around the nail bed.

Inspectors wroteBased on observation, interview and record review, for one of two sampled residents (Resident 10), who were investigated for accident hazards, the facility failed to ensure the environment was free from accident hazards when Resident 10's low air loss mattress was not secured to the bed frame. This failure had the potential to result in avoidable falls.

Inspectors wroteBased on observation and interview, the facility did not have the required staffing information posted. This failure had the potential to result in lack of staffing information for viewing by residents and visitors.

Inspectors wroteBased on observation and interview, the facility had 36 resident rooms (Rooms 100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 118, 200, 202, 204, 206, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225) with multiple beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of residents' belongings.