Elon Manor Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to promote and facilitate one (1) of one (1) resident's choice to close the room door at night for privacy and personal comfort (Resident #39); and two (2) of two (2) residents right to use electric wheelchairs to support mobility, independence, and the resident's highest practicable level of functioning (Resident #s 44 and 96). This failure caused Resident #44 frustration, anxiety, mental anguish, and self-isolation, which resulted in psychological harm.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were followed related to: 1) staff performing hand hygiene when completing medication administration, 2) cleaning of multi-use equipment, such as blood glucose monitors and blood pressure cuffs, in between uses on residents, and 3) an uncleanable surface in one of two resident shower rooms in the one west unit.

Inspectors wroteBased on observations, facility record review and staff interviews, the facility failed to ensure handrails were affixed to the wall in a safe and secure manner in two floors (200 and 100) of two floors observed, during three days (2/22/2026, 2/23/2026, and 2/24/2026) of four days observed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to notify the Power of Attorney (POA) of a change in condition related to weight loss for one resident (#41) out of five residents reviewed for nutrition.

Inspectors wroteBased on observation and interview, the facility did not ensure a clean and home-like environment in two resident rooms (103 and 201) out of 25 rooms observed, and in one shower room (West Unit) of two observed.

Inspectors wroteBased on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#5) of 52 residents reviewed for PASARRsFindings included:Review of the admission record showed Resident #5 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included Parkinsonism, mood disorder, depression, psychosis and cognitive communication deficit. Review of a level I PASARR for Resident #5 dated 9/11/25 revealed a completed Level I PASARR with qualifying diagnoses. The review showed the Level I PASARR was complete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 2/25/26 at 12:46 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) related to nail care were provided for one resident (#9) out of three residents sampled.

Inspectors wroteBased on observation record review and interview, the facility failed to ensure physician orders for oxygen were followed for one resident (#24) out of two residents sampled and failed to ensure the resident had physician orders for oxygen use for one resident (#54) out of two residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Thirty-three medication administration opportunities were observed, and two errors identified for two (#49 and #92) of five residents observed. These errors constituted a 6.06% medication error rate. Findings Include:On 2/24/2026 at 11:15 a.m. an observation of medication administration with Staff B, Licensed Practical Nurse (LPN) conducted with Resident #49. Staff B, LPN performed HH, removed an Novolog FlexPen injector pen from the medications cart. She verified the insulin type/expiration, attach a new needle and turned the dosage dial to administer 4 units. Cleaned the insertion site with alcohol and let it dry and administered the medication. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to implement an accurate and up to date system for the accounting of residents' personal funds entrusted to the facility for three (#3, #5, and #6) of three residents sampled for resident funds review.

Inspectors wroteBased on record review and interview, the facility failed to ensure personal funds deposited with the facility were conveyed to the resident or resident representative within thirty days after discharge or death for three (#4, #7, #8) of three residents sampled for return of funds in a timely manner.

Inspectors wroteBased on observation record review and interviews, the facility failed to ensure adequate management of tube feeding services for two (#1 and #9) of two sampled tube fed residents out of a total of nine sampled residents related to inaccurate dating of enteral product, non-labeling of product type, rate and time of administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure a prompt resolution to a grievance for one (#3) of nine sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure the Dietary Manager met the mandatory minimum qualifications for the Dietary Manager position.

Inspectors wroteBased on observations and interviews the facility failed to ensure the environment was clean and free from bio-growth for one Hopper Room (East Hallway on the 1st Floor) of four Hopper Rooms observed in the facility.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure food was held at a safe and appropriate holding temperatures prior to food tray distribution. The failed practice had the potential to affect 67 of 69 residents in the facility:

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one resident (#8) out of one resident sampled was properly assessed and monitored for self-administration of an inhaler.

Inspectors wroteBased on record reviews and interview the facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for two residents (#49 and #67) out of two sampled for resident assessments.

Inspectors wroteBased on observations, record review, and interviews the facility failed to develop a patient-centered care plan for one resident (#30) out of thirty-three sampled residents related to behavioral monitoring with the use of psychotropic medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to conduct an accurate smoking assessment for one resident (#32) out of three residents sampled for smoking. Finding Included: On 12/18/23 at 11:55 a.m., Resident #32 was observed outside in the designated smoking area smoking a cigarette without supervision. The resident was observed with a band aid and burn marks on his left fingers. The resident said when his cigarette burns, he is not able to feel it because he has neuropathy so that's why he has burn marks on his fingers. Review of admission Record, dated 12/19/2023, showed Resident # 32 was originally admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus, Atherosclerotic heart disease of native coronary artery without Angina Pectoris, and unspecified lack of coordination. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure wound care for one resident (#17) was provided care per assessment and orders were clarified with the provider out of one resident sampled for pressure ulcer care.

Inspectors wroteBased on record reviews and interviews the facility failed to provide appropriate care and services to one resident (#21) out of one resident sampled for bladder and bowel management related to inaccuracy and incomplete documentation of bowel movements and transfer to an acute care facility with a diagnosis of bowel impaction.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure 1) medications were stored and labeled properly in two (1 West-East and 2 West) of three medication carts and three of three nursing stations, and 2) medications were inaccessible to residents, visitors, and unauthorized personnel in three of three nursing station/medication rooms and two of three medication carts.

Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment in a safe, operating condition, related to one burner on the stove. The stove was used to provide meals for residents on two of two floors of the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that each resident was accurately assessed for their Preadmission Screening and Resident Review (PASRR) needs for one (Resident #36) of 29 sampled residents.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to, (1) discard medications in an appropriate manner on one (2 East) of four units, (2) ensure Schedule IV medications were stored within a double-lock system in two of two medication refrigerators, (3) label medications with an open date and discard medications within the shortened shelf life on two (1 East and 2 West) of three medication carts, and (4) ensure one of three medication carts and one treatment cart were locked while unattended.

Inspectors wroteBased on observation and interview, the facility failed to ensure that food was prepared in a clean and sanitary manner in the kitchen related to 1) Food left uncovered and exposed to contaminates and 2) Non dietary staff in the kitchen without a hairnet. The kitchen was used to prepare meals for residents on two of two floors of the facility. Findings Included: On 09/13/21 at 09:57 a.m. an initial tour of the kitchen with the Certified Dietary Manager (CDM) was conducted. During the tour, dough that had been formed into rolls was observed, uncovered, sitting on top of an oven. The dough was observed to be sitting, uncovered, underneath a stained, greasy substance, and peeling rust. The CDM confirmed that the rolls were placed there by the cook for proofing (to allow the dough to rise) and would be used for lunch. [...]