Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elm Crest Retirement Community during CMS and state inspections, most recent first.
Food was not prepared, held, and delivered at proper temperatures. Several residents reported meals were often cold or not always warm, and one resident said the food did not taste very good. During lunch service, a tray cart sat in the hallway before delivery, and the ground chicken was checked at 110 degrees F at the end of service, below the facility’s required hot-holding temperature of 135 degrees F.
A facility failed to serve meals according to ordered therapeutic diets for 5 residents with mechanical soft orders. During lunch service, residents were served sweet and sour sauce containing pineapple chunks even though the mechanical soft menu called for a different fruit preparation and no chunk pineapple. The RDN said she believed a red sauce with ground fruit was being used and agreed the mechanical soft diet should not include chunk pineapple.
Unclean kitchen and incomplete food storage practices. The kitchen had dirty coolers, unlabeled and undated food items, food stored on the floor, dirty carts, and a pantry with a strong odor and overfull trash. Freezers lacked internal thermometers, the ceiling and vents were discolored, a ceiling tile was missing, and water was dripping near a sprinkler. Staff also reported incomplete cleaning logs and that the facility was operating without a CDM, with the ADM and RD covering kitchen duties.
Staff did not consistently follow the care plan and therapy recommendations requiring two-person assistance for transfers of a resident with significant physical and cognitive impairments, resulting in a fall during a transfer when only one staff member assisted. Interviews indicated confusion among staff about the required level of assistance, and previous incidents of falls had already been documented for this resident.
A resident with a history of falls and requiring substantial assistance was not provided with safe transfer techniques, resulting in multiple falls and injuries. The resident fell in the bathroom without a gait belt or proper footwear, leading to a C3 fracture and skin tears. Staff interviews revealed inadequate orientation and lack of access to resident information for a CNA, who assisted the resident alone despite needing two-person assistance. The facility's policy required gait belts, but they were not used during the incident.
The facility failed to maintain proper dish sanitization standards, with the dish machine operating below required temperatures for both wash and rinse cycles. Staff continued to use dishes washed at inadequate temperatures, and temperature checks were not effectively conducted. The issue persisted despite maintenance visits, and the facility's policy for verifying dish machine temperatures was not consistently followed.
The facility failed to implement proper infection control measures and Enhanced Barrier Precautions (EBP) for three residents. A resident with an indwelling catheter did not receive care with appropriate hand hygiene or gown use. Another resident with a G-tube did not have gown precautions followed during care. Additionally, an LPN did not change gloves between administering nasal and ocular medications. The DON confirmed that staff were expected to follow hand hygiene and PPE protocols.
A facility failed to complete a comprehensive MDS assessment for a resident, missing data in Section GG on functional abilities. The DON and MDS Coordinator could not explain the oversight, despite the expectation for full completion. The PTA provided input for the section, but it remained incomplete, contrary to the facility's policy.
A facility failed to create a comprehensive care plan for a resident diagnosed with MRSA. Despite the diagnosis and treatment order, the care plan lacked focus, goals, or interventions for MRSA, and enhanced barrier precautions were not implemented. Staff acknowledged the oversight, and the facility's policy for comprehensive care planning was not followed.
A facility failed to consistently implement a restorative ambulation program for a resident with neuropathy and diabetes, as outlined in their care plan. Despite the resident's intact cognition and a goal to ambulate 500 feet daily, documentation showed inconsistencies in the program's execution. The resident reported not walking to meals as intended, and the DON confirmed the program was not followed as written.
A resident with COPD did not receive proper respiratory care as the facility failed to maintain nebulizer equipment according to protocol. The nebulizer tubing and mask were not regularly cleaned or dated, and staff interviews revealed a lack of adherence to the facility's policy for nebulizer management.
A resident with severe cognitive deficits was treated with a lack of dignity and respect by a staff member in an LTC facility. The resident, who was restless and attempted to stand unassisted, was subjected to a harsh tone and physical contact by an untrained staff member, leading to an escalation where the resident bit the staff member. The staff member reacted by pushing the resident's forehead, contrary to the facility's dignity policy.
The facility failed to update care plans for four residents, leading to discrepancies between documented care needs and actual resident abilities. A resident was observed self-propelling a wheelchair despite the care plan requiring two staff for transfers. Another resident's care plan did not reflect their independence with a walker. A third resident's care plan required maximum assistance for transfers, but observations showed they needed less help. Lastly, a resident's care plan included outdated hospice interventions and fall checks that were not documented.
The facility failed to complete necessary assessments and follow protocol for two residents who sustained falls with major injuries. One resident with severe cognitive impairment experienced a delayed post-fall evaluation, while another resident with intact cognition had an incomplete assessment. Staff interviews revealed inconsistencies in following the facility's protocol for using mechanical lifts and completing documentation promptly, leading to deficiencies in care.
Food Served at Improper Temperature
Penalty
Summary
Food and drink were not prepared, served, and distributed in accordance with professional standards. Several residents interviewed reported that meals were often cold or not always warm, and one resident stated that the food did not taste very good and was not always hot when it should be. The residents interviewed had MDS BIMS scores ranging from 9 to 13, reflecting moderate cognitive impairment for some and intact cognitive functioning for another. During lunch service, a room tray cart was observed sitting in the north hallway for several minutes before delivery, and then remained across from the nurses station for approximately 8 more minutes before being delivered. The menu for the meal included diced chicken on rice with sweet and sour sauce, and the mechanical soft menu required ground chicken. At the end of service, the ground chicken was checked and found to be 110 degrees Fahrenheit. The dietician agreed the ground meat should have maintained a higher temperature throughout service and noted there may have been an element out on that steam table. The facility policy required hot foods to be held and served at least 135 degrees Fahrenheit and transported as quickly as possible to maintain temperature.
Therapeutic Diet Meals Served Inconsistent With Ordered Texture
Penalty
Summary
The facility failed to ensure that residents were served meals according to their specific therapeutic diet orders for 5 of 46 residents reviewed. The menu for the lunch meal on 1/12/26 listed diced chicken on rice with sweet and sour sauce, stir fry vegetables, a fortune cookie, and fruit cocktail, while the Mechanical Soft therapeutic menu called for ground chicken, no changes to the rice or sauce, broccoli florets instead of stir fry vegetables, omission of the fortune cookie, and peach and/or pears instead of fruit cocktail. The menu had been signed by the dietician on 6/19/25. Record review showed that Resident #9, Resident #25, Resident #31, Resident #47, and Resident #48 each had orders for a regular diet with mechanical soft texture, with varying liquid consistencies and ground meat or other texture modifications. During lunch observation on 1/12/26 at 11:45 AM, these residents were served sweet and sour sauce that included pineapple chunks. At 2:23 PM, the Dietician stated she was surprised to learn that the mechanical soft diets had been served pineapple chunks in the sweet and sour sauce and said she believed they were using a red sauce with ground fruit. She agreed that the mechanical soft diet should not include chunk pineapple and stated that she had recently provided education to kitchen staff on the different diets. The facility policy stated that therapeutic diets would be individualized to meet residents' clinical needs and that diets should coincide with the therapeutic diets on the menu extensions.
Unclean kitchen and incomplete food storage and sanitation practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, and the kitchen was observed to be unclean during the initial walk through. The chocolate milk cooler contained dirty crates, walls with spilled chocolate milk residue, and a black residual along the lid hinge, and it did not have an internal thermometer. The cooler holding white milk, sour cream, and cottage cheese had frost along the inside walls, and the thermometer was upside down. A side-by-side refrigerator contained an unidentified opened food item in a clear container that was not dated, and another refrigerator contained a metal basin with separate containers of brown lettuce, partially uncovered shredded cheese, and an unidentifiable white substance. The dry pantry had a strong odor, a trash can more than half full, boxes of food on the floor, stacked broken cardboard boxes, and two large dry good storage containers without labels identifying the food item or when it was opened. Additional observations showed the pantry freezers did not have internal thermometers, the walk-in cooler had boxes and bags of food on the floor, undated opened chocolate milk, and a basin with melting ice containing food and opened liquid items. The main kitchen had two dirty carts with food items left on them, and the ceiling and vents throughout the kitchen had brown to black discoloration and areas with a discolored raised fuzzy texture. A ceiling tile was missing near the chocolate milk cooler, and slow dripping water from the ceiling was observed near a fire suppressant sprinkler. Staff interviews confirmed the kitchen did not have a Certified Dietary Manager and that the Administrator and RD were jointly covering kitchen responsibilities. Staff also stated the ceiling had a history of dripping when storming, but it was not storming at the time, and one staff member said the missing ceiling tile had been absent for over a month. Review of refrigerator/freezer logs and cleaning charts showed incomplete documentation. The 12/25 refrigerator/freezer logs had no entries for 12/20 and 12/21/25. Weekly cleaning charts were missing for October, only one was provided for November, and each of the 10 weekly logs reviewed was not thoroughly completed. Monthly cleaning charts were also incomplete, with no log present for August and only partial documentation of cleaning tasks recorded on the July chart. Staff stated they did not always complete cleaning logs while doing the cleaning in the kitchen, and the Administrator stated the kitchen cleaning routine may not have been as formal after the CDM left in November. The facility's sanitation policy required a written, comprehensive cleaning schedule with employees initialing and dating completed tasks.
Failure to Use Safe Transfer Techniques for High-Risk Resident
Penalty
Summary
Staff failed to use safe transferring techniques for a resident with a history of multiple falls and significant physical and cognitive impairments. The resident, who had diagnoses including renal insufficiency, neurogenic bladder, diabetes mellitus, cerebrovascular accident, and chronic pain, required substantial assistance for transfers and was care planned for two-person assistance. Despite this, on one occasion, only one staff member assisted the resident in transferring from the toilet to a wheelchair, resulting in the resident sliding to the floor. The care plan had been updated to specify two-person assistance for transfers, especially when no grab bar was available, and therapy recommendations also indicated the need for two staff during transfers. Interviews with staff revealed inconsistent understanding and implementation of the required level of assistance, with some staff unsure whether one or two people were needed for transfers. Documentation showed previous incidents where the resident was found on the floor or lowered to the floor during transfers, and interventions were put in place to address these risks. However, the failure to consistently follow the care plan and therapy recommendations led to another fall event. The facility's policy required individualized fall risk assessment and care planning, but these were not effectively implemented for this resident.
Failure to Use Safe Transfer Techniques Leads to Resident Falls
Penalty
Summary
The facility failed to use safe transfer techniques for a resident, leading to multiple falls and injuries. Resident #37, who had a minimal cognitive deficit and required substantial assistance for transfers, fell in the bathroom and sustained bruising and a skin tear after staff assisted him without a gait belt or proper footwear. The resident had a history of falls and was at high risk for falling due to previous falls at home. Despite this, the care plan did not include adequate interventions to prevent further falls. On one occasion, the resident fell in his room while attempting to go to the bathroom, resulting in a C3 fracture and a skin tear. The resident was sent to the emergency room for evaluation and was later admitted to the hospital. Upon returning to the facility, the resident was placed on 15-minute visual checks, and new gripper socks were provided. However, the care plan lacked updates or new interventions following another fall on November 6, 2024, when the resident fell in the bathroom while being assisted by staff without a gait belt or proper footwear. Staff interviews revealed that a Certified Nurse Aide (CNA) had limited orientation and was not able to access the electronic chart for resident information. The CNA was informed that the resident required two-person assistance, but another aide left the room, leaving the CNA to assist the resident alone. The facility's policy required the use of gait belts for residents needing assistance with transfers, but the CNA did not use one, believing it was unnecessary because the resident had a walker. The facility's Director of Nursing confirmed that gait belts were supposed to be used and were kept in residents' rooms, but the CNA reported that there were no gait belts available in the resident's room at the time of the incident.
Improper Dish Sanitization in LTC Facility
Penalty
Summary
The facility failed to adhere to proper sanitation standards by serving residents on dishes that were not rinsed at the appropriate temperature in the dish machine, potentially spreading illness. Observations on November 12 revealed that the high-temperature dish machine was operating with a wash cycle temperature of 140 degrees and a rinse cycle temperature of 170 degrees, both below the required standards. The facility's Temperature Monitoring Form for October documented several instances where the wash and rinse temperatures were below the required 150 degrees and 180 degrees, respectively. Staff M, a Dietary Aide, admitted to continuing to wash and store dishes even when the dish machine temperatures were below the required levels, believing that a rinse temperature above 150 degrees was sufficient. Staff M used temperature strips to check the rinse temperature, but these strips did not change color, indicating that the required temperature was not reached. Staff N, the Certified Dietary Manager, acknowledged the issue and stated that the dish machine had not been reaching the necessary rinse temperature of 180 degrees. Despite a maintenance visit on November 6, there was no service request for low temperatures, and the technician confirmed that the machine did not reach the required rinse temperature during his tests. The facility's policy required staff to verify proper temperatures and machine function before use, but this was not consistently followed. The Administrator confirmed the facility's expectations for dish machine temperatures and the protocol for notifying management if temperatures were not met. However, the staff did not consistently follow these procedures, leading to the use of inadequately sanitized dishes.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. Resident #33, diagnosed with renal insufficiency, neurogenic bladder, and septicemia, and a carrier of MRSA, was observed during a catheter care procedure where the CNA did not perform hand hygiene or wear a gown, contrary to the care plan's special instructions for enhanced precautions. The CNA admitted to being unaware of the enhanced barrier precautions required for residents with catheters. Resident #9, with a history of hemiplegia, seizure disorder, traumatic brain injury, and gastrostomy status, was also a carrier of MRSA. During a procedure involving the resident's G-tube, the RN performed hand hygiene but did not don a gown, as required by the care plan's special instructions for enhanced precautions. The RN was unaware that gowns should be worn during G-tube care. Both the DON and the Administrator confirmed that their expectations were for hand hygiene and PPE to be used appropriately, and for EBP to be followed during catheter care. Resident #21, with a moderate cognitive deficit and a history of visual and swallowing deficits, was observed during a medication pass where the LPN failed to change gloves between administering nasal and ocular medications. The DON stated that nurses were taught to change gloves between different medication routes and perform hand hygiene before donning a new pair of gloves. The facility's policy on handwashing and glove use was not adhered to, as gloves were not changed between different routes of medication administration.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required timeline for one resident. Specifically, the MDS Quarterly assessment for the resident lacked data or a reason for non-assessment in Section GG, which pertains to functional abilities. The previous Quarterly MDS for the same resident had been completed in its entirety, indicating a lapse in the current assessment process. The Director of Nursing (DON) and the MDS Coordinator were unable to provide an explanation for the incomplete section, despite the expectation that the document should be fully completed. Interviews with facility staff revealed that the MDS is typically completed through coordination between the facility's MDS Coordinator and a Corporate MDS Consultant. However, the current MDS Coordinator was not in the position at the time of the incomplete assessment and could not provide details on the oversight. The Physical Therapist Assistant (PTA) mentioned providing input for Section GG, but the section remained incomplete. The facility's policy on comprehensive assessments, revised in October 2023, mandates that MDS assessments be completed according to the criteria outlined in the RAI User Manual, which was not adhered to in this instance.
Failure to Develop Comprehensive Care Plan for MRSA Diagnosis
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Despite the electronic health record indicating a new order for Bactrim DS and a diagnosis of MRSA, the resident's care plan lacked any focus, goals, or interventions related to this diagnosis. The Minimum Data Set (MDS) assessment did not document an active diagnosis of a multidrug-resistant organism (MDRO), and the care plan did not address the necessary enhanced barrier precautions (EBP) for the resident. Interviews with staff revealed that the care plan for the resident was not updated to include the MRSA diagnosis. Staff G, responsible for writing care plans, acknowledged the absence of a care plan for MRSA. The Director of Nursing (DON) also confirmed that there was no sign outside the resident's door indicating the need for enhanced barrier precautions, which should have been in place. The facility's policy requires comprehensive, person-centered care plans developed by an interdisciplinary team, but this was not adhered to in the case of the resident with MRSA.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the mobility of a resident, identified as Resident #12, who was part of a review involving two residents. Resident #12 had a documented history of hypertension, diabetes mellitus, neuropathy, and severe visual impairment, with intact cognition as indicated by a BIMS score of 15. The resident's care plan included a focus on an ambulation restorative nursing program due to neuropathy and diabetes, with a goal of ambulating 500 feet daily. However, the restorative program documentation for the last 30 days showed inconsistencies in the resident's ambulation records, with multiple entries on certain days and numerous entries marked as not applicable, indicating a lack of consistent implementation of the program. Interviews and observations revealed that Resident #12 was not consistently walked to meals as per the restorative program. The resident expressed that she was supposed to walk to the dining room for every meal but was no longer doing so. The Director of Nursing acknowledged that the resident was not being walked to meals as the program was written, and the facility's policy on Restorative Nursing Services emphasized individualized, resident-centered goals. The failure to adhere to the restorative program as outlined in the care plan led to the deficiency identified in the report.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring the use of a nebulizer. The resident, who had a history of heart failure, hypertension, and asthma/COPD, was prescribed Ipratropium-Albuterol Solution to be inhaled three times a day. The care plan included interventions such as administering prescribed respiratory treatments and monitoring lung sounds and oxygen saturations. However, observations revealed that the nebulizer equipment was not properly maintained, with tubing and mask left undated and not regularly cleaned as per the facility's policy. Staff interviews indicated a lack of adherence to the facility's protocol for nebulizer management. The Registered Nurse stated that nebulizer tubing should be changed weekly, with the date and initials marked on the tubing, but this was not done. The Health Unit Coordinator noted that the Treatment Administration Record should reflect the order to change the tubing/mask, which was missing. The Director of Nursing acknowledged the difficulty in tracking changes without proper documentation. The facility's policy required disconnection, rinsing, disinfecting, and air drying of nebulizer equipment, with changes every seven days, which was not followed in this case.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving Resident #96. The resident, who had a severe cognitive deficit and was at high risk for falls, was subjected to demeaning and forceful behavior by a staff member, Staff D. The resident was restless and attempted to stand up unassisted, prompting Staff D to use a harsh tone and physical contact to keep her seated. This interaction escalated when the resident bit Staff D, who then reacted by pushing the resident's forehead. Staff interviews revealed that Staff D was not trained to monitor residents and was not equipped to handle such situations. Despite being instructed to use non-medical interventions for the resident's anxiety, Staff D used a firm voice and physical restraint, which was not in line with the facility's dignity policy. Other staff members, including Staff F and Staff H, witnessed the incident and reported that Staff D's actions were aggressive and not appropriate for the resident's condition. The facility's policy on dignity, which emphasizes respectful communication and sensitivity towards cognitively impaired residents, was not adhered to in this case. Staff D, who was new to the position, admitted to being unprepared and using a harsh tone with the resident. The facility's administration acknowledged that Staff D was not trained for such interactions, yet they justified her actions as an attempt to prevent the resident from falling, despite the presence of other staff in the dining room who could have assisted.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the care plans to reflect the current status of four residents. For Resident #1, the care plan did not accurately reflect the resident's ability to self-propel a wheelchair and the need for assistance with transfers. Despite observations of the resident independently moving in a wheelchair and requiring only limited assistance for transfers, the care plan still indicated the need for two staff members for all transfers and did not include a toileting program. Resident #2's care plan was not updated to reflect the resident's current level of independence. Although the resident was observed walking independently with a four-wheeled walker and was planning to discharge home, the care plan still included interventions for assistance with edema wear and toileting, which were not being followed as the resident was not wearing edema garments during observations. For Resident #3, the care plan required maximum assistance from two staff members for transfers, but observations and staff interviews indicated the resident could complete transfers with assistance from one to two staff members and actively participated in transfers. Resident #4's care plan included outdated interventions related to hospice services, which had been discontinued, and fall interventions that were not being documented or followed, as staff were unsure if visual checks were still occurring.
Failure to Complete Post-Fall Assessments and Follow Protocol
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards by not completing assessments on residents who sustained ground-level falls with major injuries. Resident #1, who had severe cognitive impairment and multiple fractures, experienced a fall on 3/25/24. However, the post-fall evaluation was not completed until 3/29/24, and the assessment was conducted by a different staff member, indicating a delay in the evaluation process. Additionally, the facility did not follow its protocol of using a full body lift to transfer Resident #1 after the fall. Resident #3, who had intact cognition and required substantial assistance for transfers, also experienced a fall. The post-fall evaluation for Resident #3 was incomplete, lacking documentation on contributing factors, medication changes, vitals, and clinical suggestions. Despite the resident being moved to a bed and then transferred to a hospital, the necessary assessments and documentation were not completed promptly. Staff interviews revealed inconsistencies in the post-fall assessment process, with staff failing to follow the facility's protocol for using a mechanical lift and completing documentation immediately. The facility's policy on fall risk prevention emphasized the need for thorough documentation after a fall to prevent further incidents. However, the facility did not adhere to its own guidelines, as evidenced by the incomplete and delayed assessments for both residents. The Director of Nursing and the Administrator expressed expectations for immediate and complete documentation, but these expectations were not met, leading to deficiencies in the care provided to the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harlan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avoca Specialty Care | 10.3 mi | ★★★★★ | 18 | 0 |
| Salem Lutheran Home | 14.3 mi | ★★★★★ | 10 | 0 |
| Dunlap Specialty Care | 19.3 mi | ★★★★★ | 0 | 0 |
| Azria Health Rose Vista | 20.8 mi | ★★★★★ | 12 | 0 |
| Friendship Home Association | 21.1 mi | ★★★★★ | 2 | 0 |
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