Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elms, The during CMS and state inspections, most recent first.
Residents were not informed how to file grievances, and the facility did not provide a way to submit written complaints anonymously. During a resident group meeting, multiple residents stated they did not know how to file a written complaint and said there was no complaint box or anonymous suggestion process. The SS Director confirmed there was no grievance box or formal anonymous complaint form, and the available concern forms were kept at the receptionist desk and nurses’ stations, including one form stored out of residents’ sight and reach.
Opened refrigerated foods were not labeled with opening or use-by dates, contrary to facility policy. During a kitchen tour, surveyors found a bag of bacon bits and multiple opened items, including salads, dairy items, condiments, and dressings, without proper date marking. The DFS stated he does not label opened foods with a use-by date and assumes the expiration date is the date to use opened foods.
Failure to Prevent Resident-to-Resident Verbal Abuse: The facility failed to prevent verbal abuse between two residents when one resident was documented yelling, cursing, and using derogatory language toward a roommate and other residents. An RN later confirmed hearing the resident call the roommate a derogatory name, and the Administrator stated that cursing toward other residents is considered verbal abuse.
The facility failed to document required IDT and psychotropic assessments before starting and increasing antipsychotic meds for two residents with dementia. One resident’s Rexulti orders changed across diagnoses including dementia, Alzheimer’s disease, bipolar disorder, and major depression, but the chart lacked the required comprehensive evaluation and psychotropic assessment. For another resident receiving Seroquel for dementia with psychosis, the MDS and care plan did not show psychosis behaviors, and staff and the family member reported the resident was generally pleasant with no current behaviors to support the medication use.
Failure to report resident-to-resident verbal abuse to the DON/Administrator and state agency. An RN heard one resident yelling at a roommate, using profane and abusive language, and later calling other residents names in the dining room, but did not notify the Administrator. The Administrator stated she was not notified and confirmed the allegation had not been reported to IDPH.
Failure to investigate and report resident-to-resident verbal abuse. A resident was documented yelling, cursing, and using derogatory language toward a roommate and other residents, but the allegation was not investigated and no final report was sent to the state agency as required by the facility’s abuse policy.
The facility failed to complete significant change assessments after two residents developed increased behaviors, new psychiatric diagnoses, and new antipsychotic medication orders. One resident had hallucinations, delusional disorder, and unspecified psychosis added, with Seroquel started, and staff acknowledged an SCSA should have been completed but was not. Another resident exhibited yelling, anxiety, exit-seeking, and agitation, then was started on Rexulti, but the MDS record did not show a Significant Change in Status MDS.
Inaccurate PASARR Coding on MDS Assessments: The facility failed to accurately code MDS Section A1500 for two residents. One resident had a PASARR Level II finding for serious mental illness, but the MDS was coded as not meeting PASARR criteria. Another resident was identified through an audit as requiring a Level II PASARR due to hallucinations and psychotropic use, but the MDS nurse did not update the MDS after being informed of the finding.
Failure to Notify State Mental Health Authority of Significant Change: A resident developed increased behaviors, was diagnosed with a new psychiatric condition, and was started on Rexulti, an anti-psychotic medication, but the EHR showed no evidence that the state mental health authority was notified. Behavior notes documented yelling at a roommate, distress about moving rooms, attempts to leave, alarm activations, throwing a cell phone, and yelling at staff, while the new medication order did not include the behaviors or diagnosis supporting its use.
A CNA failed to follow the facility’s perineal care policy during incontinence care for a resident with multiple medical diagnoses and incontinence related to activity intolerance. The CNA and another CNA entered the room wearing gowns and gloves, but the CNA did not wash hands or change gloves, placed wipes on the incontinent pad, used the same wipes to clean the resident’s vaginal area and buttocks, and applied cream without hand hygiene or glove changes. The IP, ADON, and Administrator all confirmed the care was done incorrectly.
Failure to replace and properly store oxygen tubing and nebulizer masks affected three residents receiving respiratory care. A resident with COPD and pneumonia had dated oxygen tubing that was beyond the weekly change interval, another resident with acute respiratory failure and COPD had undated tubing and cannula on the floor behind a recliner, and a third resident with lung cancer, COPD, and acute respiratory failure with hypoxia had old tubing and a nebulizer mask left on a nightstand instead of being stored in a labeled plastic bag. Staff and the IP confirmed tubing and masks should be changed weekly, dated, and stored after use.
A resident on EBP for a healed pressure wound, a healing G-tube site, and a skin tear was observed receiving high-contact care without staff wearing gowns. A CNA stated that staff had just transferred the resident from a wheelchair to bed without gowns, and the resident said staff do not always wear gowns and gloves during care, despite orders, the care plan, and the EBP door sign requiring gloves and gowns for transfers and other high-contact activities.
Survey Results Not Readily Accessible to Residents: The facility failed to keep the state survey results in a location freely accessible to residents and visitors and did not post notice that the results were available for review. During a resident group meeting, multiple residents, including the resident council president, said they were unaware of the survey binder or that past survey results could be viewed. The survey book was observed behind the receptionist desk in the lobby, and the SSW confirmed there was no signage about the binder; items in that location would not be accessible without asking for assistance.
The facility failed to ensure the daily resident census and staff posting was displayed in an area accessible to residents and visitors. Surveyors did not find the posting in the common areas or hallways, and the DON stated it was kept on a clipboard behind the receptionist desk in a file slot that is not viewable unless someone goes behind the desk and removes it. The CMS Form 671 documented 66 residents in the facility.
A resident with a complex cancer history and ongoing immunotherapy was admitted for skilled rehab after hip surgery under Medicare Part A. During admission, staff failed to identify the active immunotherapy regimen, and the DON/ADON contacted the oncologist’s office requesting that treatment be placed on hold, citing insurance reasons. Social services later told the family that immunotherapy could resume only after the resident came off Medicare A and transitioned to private pay, leading the family to request an early end to skilled coverage so they could restart treatment. The resident and family reported being told that oncology care could not occur while on Medicare benefits, and the oncologist’s office documented multiple calls from facility staff to hold treatment and a later call from the family to resume once Medicare A ended. These actions and miscommunications resulted in delayed immunotherapy and missed oncology appointments, conflicting with the resident’s rights to be informed, participate in care planning, and receive assistance in exercising those rights.
The facility failed to maintain contact precautions for a resident with ESBL, placing them in a shared room without proper PPE use by staff. Additionally, staff did not follow hand hygiene and glove protocols during medication administration for two residents, acknowledging the oversight. These deficiencies were noted during a survey of the facility's infection control program.
A facility failed to implement pressure-relieving interventions for a resident at risk for pressure ulcers, resulting in the development of a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe. The care plan was not updated, and physician-recommended treatments were not consistently applied, leading to avoidable pressure injuries.
The facility failed to assess, monitor, and document the ongoing status of a venous stasis ulcer for a resident. Despite following the physician's orders for wound care, the facility did not conduct or document any wound measurements or assessments, relying solely on the wound clinic's documentation.
The facility failed to use a gait belt during the transfer of a resident who requires staff assistance, contrary to the resident's care plan and the facility's policy. A CNA was observed lifting the resident by placing forearms under her armpits instead of using a gait belt, and an LPN confirmed that a gait belt is typically used for this resident's transfers.
The facility failed to address a significant weight loss in a resident, develop and implement interventions to prevent further weight loss, and ensure dietitian assessment. The resident's care plan and medical record lacked documentation and interventions, and the dietitian was not notified of the weight loss since November 2023.
The facility failed to ensure ongoing communication with the dialysis center and did not implement a care plan for a resident requiring dialysis services. The resident's care plan lacked details on monitoring, care, or emergency management of the dialysis access site, and several Hemodialysis Communication Forms were missing.
The facility failed to document and monitor target behaviors for two residents using antipsychotic medications. One resident with Dementia and Severe Depressive Disorder was prescribed Zyprexa, but their behaviors were not tracked every shift. Another resident with Dementia and Delusional Disorder was prescribed Seroquel, but no behaviors were documented to justify its use. Staff confirmed that behavior tracking was not consistently performed.
A facility failed to ensure accurate administration of a blood pressure medication according to the physician's order. An LPN prepared a double dose of Labetalol for a resident, but upon rechecking the order, corrected the mistake before administration.
The facility failed to apply gloves prior to providing high-contact care and did not ensure appropriate isolation precautions for a resident with an active infection. Despite the facility's Enhanced Barrier Precautions policy, staff were observed transferring the resident without gloves, and the resident was not placed under the required contact isolation precautions.
Residents Not Informed How to File Grievances or Submit Anonymous Complaints
Penalty
Summary
The facility failed to ensure residents were informed of how to file a grievance and failed to ensure that written complaints could be submitted anonymously. The facility’s Grievance/Complaint policy, dated 3/25/26, stated that each resident and/or resident representative may file a grievance or complaint regarding resident rights, quality of life, or quality of care concerns, and that the party filing the grievance may present it anonymously. The policy also identified the Social Services Director and DON as the designated coordinators and stated that forms were located in the social services office, north and south nurses’ stations, and front reception desk. During a resident group meeting on 6/2/26, R10, R14, R64, and R66 all denied knowing how to file a written complaint or grievance. These residents also stated the facility did not have a complaint box or a place to put anonymous suggestions or complaints. Later that day, the Social Services Director confirmed the facility did not have a grievance box or a formal complaint form that could be submitted anonymously, and stated that missing item/concern forms were available at the receptionist desk and nurses’ stations. When the form was located at the North Hall nurses’ station, it was found in a wall filing slot behind the nurses’ station and above the Social Services Director’s head, and the Social Services Director confirmed it would need to be given to a resident by staff because it was out of sight and reach of residents. The Social Services Director also stated there was not a grievance box, sign, or a way to submit the form anonymously. The CMS Form 671 dated 6/1/26 and signed by the Administrator documented 66 residents in the facility.
Opened refrigerated foods not date marked
Penalty
Summary
The facility failed to label opened food items in the refrigerators in accordance with its Food Receiving and Storage policy and its Refrigerators and Freezers policy. The policies stated that foods stored in the refrigerator or freezer are to be covered, labeled, and dated, and that refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. The facility also documented that all food is to be appropriately dated to ensure proper rotation by expiration dates, and that use-by dates are to be indicated once food is opened. During the initial kitchen tour on 6/1/2026 at 9:15 AM, surveyors observed a bag of bacon bits in the refrigerator that was not marked with an opening date. Several opened food containers were also not properly date marked, including macaroni salad, mustard potato salad, Summer Fresh pasta salad, tuna salad, cottage cheese, pickles, two containers of sauteed vegetable base, two containers of strawberries, cheesecake, sour cream, mustard salad, western salad dressing, mayonnaise, pickle relish, Caesar dressing, and Thousand Island dressing. At 9:25 AM, the Director of Food Service stated he does not label foods opened with a use by date and assumes the expiration date is the date to use opened foods.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal abuse for two residents reviewed for abuse. The facility’s Abuse and Neglect Prevention Policy states that abuse or neglect by any individual, including other residents, is not tolerated and defines verbal abuse as oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families within hearing distance. A behavior note documented that one resident was standing at the foot of a roommate’s bed, yelling and cursing at the roommate and telling the roommate to get out of the bed, pay the bill, and calling the roommate derogatory names. The same note also documented that the resident left the room and went to the south dining room, where the resident began calling other residents derogatory names. Progress notes later documented that the resident was moved to another room related to concerns with the roommate. An RN later stated that on the date of the incident, the RN heard the resident yelling at the roommate and calling the roommate a derogatory name, and the Administrator stated that a resident cursing toward other residents is considered verbal abuse.
Failure to Document Required Assessments and Justification for Antipsychotic Use
Penalty
Summary
The facility failed to ensure the Interdisciplinary Team completed and documented a comprehensive evaluation before starting and increasing an antipsychotic medication for two residents with dementia diagnoses. The facility’s psychotropic medication policy required documentation of the resident’s physical, behavioral, mental, and psychosocial status, comorbid conditions, distress, functional changes, complaints, behaviors, symptoms, and PASARR evaluation before initiating or modifying psychotropic therapy, but those assessments were not found in the records reviewed. For one resident, records showed Rexulti was started for agitation associated with dementia, later linked in orders to Alzheimer’s disease, bipolar disorder, and major depression, with dose changes over time. The chart did not include an IDT assessment before Rexulti was initiated or a psychotropic drug assessment after the medication began. The informed consent form stated the medication was for dementia with behaviors and agitation, and staff confirmed that no anti-psychotic assessments had been completed for this resident. For the second resident, records showed Seroquel was being given for dementia with psychosis, but the MDS did not document behaviors indicating psychosis and the care plan described the resident as severely impaired with no delirium indicators. The resident was observed pleasant and polite, and multiple staff and the resident’s family member reported no current behaviors or violence toward others. The record also showed a dose decrease recommendation for quetiapine, but the documentation reviewed did not include a consistent, clinically supported diagnosis or behavior record to justify the antipsychotic use.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report resident-to-resident verbal abuse to the administrator and the state agency for two residents reviewed for abuse. The facility’s Abuse and Neglect Prevention Policy required employees to report any suspected mistreatment to a department head or the Administrator, and to complete initial reports immediately but no later than 24 hours after an alleged abuse incident to IDPH. A behavior note documented that one resident was standing at the foot of a roommate’s bed, yelling and cursing at the roommate, telling the roommate to get out of the bed, pay the bill, and calling the roommate a bi**h, then later went to the south dining room and called other residents bi**hes. An RN stated she heard the resident yelling at the roommate and calling the roommate a bi**h, but she did not notify the administrator. The Administrator stated she did not recall being notified and confirmed the verbal abuse allegation involving the roommate had not been reported to the state agency.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate and submit a final report to the state agency regarding a resident-to-resident verbal abuse incident involving two residents. The facility’s Abuse and Neglect Prevention Policy states that an investigation will begin by obtaining documentation related to the incident and that the administrator is responsible for forwarding a final written report of the investigation and any corrective action to the Department of Public Health within five working days of the reported incident. A behavior note documented that one resident was standing at the foot of the roommate’s bed, yelling and cursing at the roommate, telling the roommate to get out of the bed, calling the roommate a bi**h, and stating the roommate was doing nothing and should pay the TV bill. The same note also documented that the resident later went to the south dining room and called other residents bi**hes. On interview, the administrator verified that the verbal abuse allegation involving the roommate had not been investigated and that a final report had not been sent to the state agency.
Failure to Complete Significant Change Assessments After Behavioral and Psychiatric Changes
Penalty
Summary
The facility failed to complete a significant change comprehensive assessment after residents showed increased behaviors, received new psychiatric diagnoses, and were started on new antipsychotic medications. The report states that for residents with MI or ID/DD, a Resident Review is required when there is a significant change in physical or mental condition, and that when an SCSA is completed for a resident with MI/DD, the nursing home must notify the appropriate state mental health or developmental disability authority. The deficiency involved two residents reviewed for significant change in condition out of a sample of 30. For one resident, the medical record showed hallucinations, delusional disorder, and unspecified psychosis added to the diagnosis list, and Seroquel 25 mg daily was started for confusion and hallucinations. Facility staff stated that a PASARR audit identified the resident as requiring a Level II PASARR, and the DON, Social Services Director, and MDS Nurse acknowledged that a Significant Change in Status Assessment should have been completed but was not. For the second resident, behavior notes documented yelling, anxiety, attempts to leave, alarm activations, throwing a cell phone, and yelling at staff, followed by a new order for Rexulti 0.5 mg daily. The MDS tracking record did not show evidence of a Significant Change in Status MDS after the increased behaviors and start of Rexulti.
Inaccurate PASARR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code MDS assessments for two residents, R3 and R4, in Section A1500 regarding PASARR Level II screening status. The facility’s Comprehensive Assessments policy states assessments are to be completed according to the RAI User Manual, which instructs that Code 1 is used when PASARR Level II screening determines a resident has a serious mental illness and/or ID/DD or related condition. R4’s PASARR Level II outcome dated 3/9/25 stated that R4 met PASARR inclusion criteria for serious mental illness with diagnoses of Major Depressive Disorder and Psychosis, but R4’s MDS assessments dated 1/27/26 and 4/28/26 were coded to indicate that R4 was not considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or related condition. The DON verified that these MDS assessments were inaccurately coded and should have reflected that R4 did have a serious mental illness according to the PASARR determination. R3’s physician orders showed Seroquel 25 mg daily was started on 8/21/23 for confusion and hallucinations. The DON stated the facility completed an audit of PASARR determinations in January 2026, reviewed resident diagnoses and medications, and identified residents requiring a Level II PASARR, including R3. The Social Services Director stated R3 was identified as requiring a Level II PASARR due to increased hallucinations and the initiation of psychotropic medication and that this information was communicated to the MDS nurse. The MDS nurse stated she knew R3 had been identified as requiring a Level II PASARR but did not update the MDS assessment because she believed completion of the PASARR process alone addressed the issue.
Failure to Notify State Mental Health Authority of Significant Change
Penalty
Summary
The facility failed to notify the state mental health authority when R16 experienced an increase in behaviors, was diagnosed with a new psychiatric condition, and was started on a new anti-psychotic medication. R16’s MDS dated 10/15/25 documented that R16 did not receive anti-psychotic medication, but subsequent behavior notes showed escalating behaviors, including yelling at a roommate, expressing distress about moving to south hall, attempting to leave, setting off alarms twice, throwing a cell phone, and yelling at staff. On 12/10/25, a new order from the psychiatric nurse practitioner started Rexulti 0.5 mg daily, and the order did not include the behaviors or diagnosis to warrant its use. The resident’s electronic health record did not show evidence that the state mental health authority was notified after the increase in behaviors and the start of Rexulti. On 6/3/26 at 8:15 AM, V4 verified that once R16 began exhibiting new behaviors and was started on an anti-psychotic medication for a mood disorder, the state mental health authority was not notified.
Incontinence Care Performed Without Required Hand Hygiene or Glove Changes
Penalty
Summary
The facility failed to follow its perineal care policy during incontinence care for one resident who was incontinent related to activity intolerance and had diagnoses including acute respiratory failure with hypoxia, essential hypertension, acute kidney failure, and bacterial infections. The policy required hand hygiene and glove use before the procedure, but during care on 6/1/26, two CNAs entered the resident’s room wearing gowns and gloves, removed the disposable brief, and used disposable wipes to clean the resident without washing hands or changing gloves. One CNA placed five wet wipes on the incontinent pad under the resident, then used the same wipes to clean the resident’s vaginal area and the area between the legs and torso, and later used another five wipes in the same manner to clean the buttocks. During the same incontinence care, the CNA did not wash hands or change gloves before applying cream to the resident’s buttock. When asked about glove changes and handwashing, the CNA stated, “Sometimes, it depends on how much mess there is.” The Infection Preventionist stated the wipes should not have been placed on a dirty surface before cleaning and that the CNA should have changed gloves and washed hands. The Assistant Director of Nursing verified that the policy did not call for wet wipes and that CNAs should have used a wash basin and washcloths, and also should have washed hands and changed gloves. The Administrator stated the entire incontinent care process was done incorrectly.
Failure to Replace and Properly Store Oxygen Tubing and Nebulizer Masks
Penalty
Summary
The facility failed to replace oxygen tubing and nebulizer masks weekly and failed to store or label oxygen equipment correctly for three residents receiving respiratory care. R8, who had COPD, a COPD exacerbation, and pneumonia, was observed on 6/1/2026 wearing a nasal cannula with oxygen flowing at 3L; the oxygen tubing was dated 5/23/2026. Her physician’s order directed oxygen at 3L via nasal cannula to keep oxygen saturation above 92% as needed for respiratory distress or to maintain saturation above 92%, and her care plan identified her as at risk for altered respiratory status and difficulty breathing related to her respiratory diagnoses. R21, who had acute respiratory failure and COPD, had an order for oxygen at 2 to 5 liters as needed for respiratory distress to maintain oxygen above 90%, with tubing to be changed weekly on Fridays on third shift. On 6/1/2026, her oxygen tubing and nasal cannula were found on the floor behind her recliner and were not dated, and she stated she was not sure when she last used oxygen and that no one had changed the tubing. R50, who had malignant neoplasm of the bronchus or lung, COPD, and acute respiratory failure with hypoxia, had oxygen tubing dated 5/23/2026 and a nebulizer mask dated 5/23/2026 on her nightstand; the mask was not stored in a plastic bag. Staff later verified the tubing and mask had been changed and dated, but the mask still was not stored in a plastic bag. The Infection Preventionist stated oxygen tubing and nebulizer masks should be changed every week and dated, and nebulizer masks should be cleaned and stored after use.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for one resident who had been placed on EBP due to a pressure wound and a G-tube, with the G-tube later removed and the resident remaining on EBP because the site was still healing and the resident also had a skin tear to the left lower extremity. The resident’s medical record, order summary, care plan, and door sign all documented that staff were to wear gloves and a gown for high-contact resident care activities, including dressing, bathing, transfers, linen changes, hygiene, toileting, wound care, and device care. During observation, the resident was seen in bed while a CNA and an agency CNA were checking for incontinence, and neither staff member had a gown on. The CNA stated that the resident had just been transferred from a wheelchair to the bed to change the resident and that neither staff member wore a gown during the transfer. The resident stated that staff do not always wear gowns and gloves when providing care. The Infection Preventionist stated that the resident was on EBP and that a gown and gloves should be worn when transferring or providing care for the resident.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and failed to post a notice that survey results were available for review. During a resident group meeting on 6/2/26, R10, R14, R64, and R66 all stated they were not aware of a state agency survey binder or that the survey results could be reviewed. R64, who confirmed she was the resident council president, stated she was not aware that residents could look at or see those past survey results. Later that day, the state agency survey book was observed in the lobby behind the receptionist desk in a three-ring binder, rather than in a freely accessible location. The lobby area and hallways did not contain any posting indicating that state agency survey results were available for review. V7, the Social Service Director, confirmed the survey book was behind the receptionist desk and stated she was not aware of any signage about the survey results binder. V7 also stated that some residents travel to the front lobby but not all do, and that items behind the reception desk would most likely not be accessible to residents without asking for assistance. The facility's CMS Form 671 dated 6/1/26 and signed by V1 documented that 66 residents resided in the facility.
Daily Staffing Posting Not Accessible
Penalty
Summary
The facility failed to ensure that the daily resident census and facility staff posting was posted in an area accessible to residents and visitors. On 6/2/26 at 11:20 AM, surveyors toured the common areas and hallways and did not find a daily staffing posting. At 11:30 AM, the DON stated the facility daily staffing is kept at the receptionist's desk. At 11:35 AM, the DON removed a clipboard from an upright file slot behind the receptionist desk in the lobby entrance and verified that the daily staff posting is placed on that clipboard and stored in the file slot every day. The DON confirmed the clipboard is not viewable unless someone goes behind the desk and removes it from the file where it is stored. The facility's CMS Form 671 dated 6/1/26 and signed by the Administrator documented 66 residents in the facility.
Delay of Oncology Immunotherapy Due to Mismanagement of Medicare Status and Communication Failures
Penalty
Summary
The deficiency involves the facility delaying a resident’s immunotherapy oncology treatment due to misunderstandings and actions related to Medicare Part A coverage and the resident’s payor status. The resident had a complex history of multiple squamous cell carcinomas, basal cell carcinoma, prostate cancer, autoimmune pancreatitis, and imaging showing a hypermetabolic renal mass and pulmonary nodule. Prior to admission, the resident had initiated immunotherapy (cemiplimab) with a plan for eight cycles. Following a ground-level fall and right femoral neck fracture, the resident underwent right hip hemiarthroplasty and was discharged from the hospital to the facility for subacute skilled therapy under Medicare benefits. The admission contract and facility resident rights policy stated that residents would be fully informed of their rights, services, and charges, and that the facility would assist residents in exercising their rights and ensure they were treated with dignity and respect. During the admission and screening process, facility staff did not identify that the resident was actively receiving immunotherapy and had ongoing oncology appointments. Admissions staff reported they did not see any immunotherapy when screening the resident, and social services reported they did not realize the resident was supposed to receive immunotherapy until after admission. The facility assessment referenced cancer-related care needs in general but did not identify any residents currently receiving cancer treatments. After admission, the DON/ADON contacted the oncologist’s office on multiple occasions requesting that the resident’s immunotherapy be placed on hold, initially citing insurance reasons and asking to hold treatment for a few weeks. Oncology documentation showed that the oncologist’s office attempted to return calls, explained that provider approval was needed to withhold treatment, and ultimately pushed out appointments until mid-December, with a note that the facility would call when ready to reschedule. Over the subsequent weeks, facility documentation and interviews show that the resident and family were informed or believed that immunotherapy could not be continued while the resident was on Medicare Part A skilled therapy. Progress notes from February indicated that social services told the family the resident could start immunotherapy once off skilled therapy, and that the resident’s last covered Medicare A day would be set so the resident could transition to private pay and Part B. The daughter then contacted the oncologist to resume immunotherapy, and family provided appointment dates to the facility once they were scheduled. In interviews, the daughter stated she was told immunotherapy had to stop while the resident was receiving therapy on Medicare benefits and that treatment could resume only after switching to private pay, and the resident similarly stated he was told he could not see the oncologist while on Medicare and could resume now that he was private pay. The oncologist’s nurse confirmed receiving calls from facility staff requesting that immunotherapy be put on hold and later a call from the daughter indicating the resident was no longer on Medicare benefits and wanted to restart treatment. These actions and communications resulted in delayed oncology immunotherapy services and missed scheduled appointments for the resident, contrary to the resident’s rights to be fully informed, to participate in care planning, and to receive assistance in exercising those rights.
Infection Control Lapses in Contact Precautions and Medication Handling
Penalty
Summary
The facility failed to maintain proper contact precautions for a resident with a known multidrug-resistant organism (MDRO), specifically ESBL in the urine. The resident, who was frequently incontinent of urine, was placed in a room with another resident under enhanced barrier precautions for wounds. Despite the presence of a sign indicating enhanced barrier precautions, staff, including CNAs, were observed entering and exiting the room without wearing personal protective equipment (PPE). The infection preventionist acknowledged that the resident with ESBL should have been in a separate room under contact precautions, which was not implemented, leading to potential exposure risk to other residents assisted by the same CNAs. Additionally, the facility failed to adhere to hand hygiene and glove use standards during medication administration for two residents. A registered nurse was observed handling medication capsules without sanitizing hands or wearing gloves, and a licensed practical nurse similarly handled medication tablets without proper hand sanitation or glove use. Both staff members acknowledged the oversight, and the Director of Nursing confirmed the necessity of hand hygiene and glove use when handling medications. These lapses in infection control practices were identified during a survey of the facility's infection prevention and control program.
Failure to Implement Pressure-Relieving Interventions
Penalty
Summary
The facility failed to develop and implement pressure-relieving interventions to prevent pressure wound development for a resident who was at risk for pressure ulcers. Despite the resident's initial Braden scale indicating a risk for pressure ulcer development, the care plan was not updated with appropriate interventions. The resident, who had a history of hip fractures and required total assistance for bed mobility and transfers, developed a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe due to the lack of preventive measures such as offloading the heels with heel protectors and floating heels with pillows while in bed. The resident's condition deteriorated over time, with the right heel pressure ulcer progressing from a stage two pressure injury to an unstageable ulcer covered with eschar. The wound physician had recommended specific treatments and interventions, including the use of collagenase and povidone-iodine, but these were not consistently implemented. Observations revealed that the resident's heels were not offloaded as required, and the resident experienced significant pain during wound care. Additionally, a treatment order for the left great toe was not processed correctly, resulting in a lack of documented treatment for several days. Interviews with facility staff, including the Assistant Director of Nursing and the Wound Physician, confirmed that the pressure ulcers were avoidable and caused by pressure. The staff acknowledged that the necessary pressure-relieving interventions were not implemented, and the resident's care plan was not updated to reflect the risk of pressure ulcer development. The failure to follow the physician's recommendations and update the care plan contributed to the development and worsening of the resident's pressure ulcers.
Failure to Document and Assess Venous Stasis Ulcer
Penalty
Summary
The facility failed to assess, monitor, and document the ongoing status of a venous stasis ulcer for a resident (R18) who was reviewed for non-pressure wounds. The facility's Wound Care policy requires detailed documentation of wound care, including the type of care given, date and time, the individual performing the care, changes in the resident's condition, assessment data, and any problems or complaints. However, R18's medical record lacked any wound measurements, assessments, or progress notes from the facility staff. The resident's care plan indicated a high risk for impaired skin integrity, and the physician's orders specified a detailed wound care regimen, which was followed by the staff during observed dressing changes. Despite this, the facility did not document any ongoing assessments or wound measurements, relying solely on the wound clinic's documentation, which was not integrated into the resident's medical record at the facility. Interviews with the Director of Nursing (V2) and the Assistant Director of Nursing (V3) confirmed that the facility did not conduct or document ongoing wound assessments or measurements for R18's venous stasis ulcer. The staff only documented that the dressing changes were completed as scheduled. The resident, who had a history of moisture-associated skin damage and other risk factors, reported having the wound for several years. The lack of proper documentation and ongoing assessment by the facility staff represents a failure to adhere to their own wound care policy and to ensure comprehensive monitoring and documentation of the resident's wound status.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt during the transfer of a resident who requires staff assistance with transfers. The facility's Transfer Belt Policy mandates the use of transfer belts for any resident requiring hands-on assistance unless specified otherwise in the care plan. Resident R29's care plan explicitly states the need for a gait belt during transfers due to her decreased mobility, poor cognition, poor activity tolerance, behaviors, and balance deficits. Despite this, a Certified Nursing Assistant (CNA) was observed transferring R29 without using a gait belt, instead lifting her by placing forearms under her armpits and moving her from her wheelchair to her bed. The CNA admitted to not using a gait belt for R29, citing that R29 does not usually get up on her own and does not put much support on her legs during transfers. Further interviews revealed that R29 requires the assistance of one staff member for transfers and does not transfer herself. A Licensed Practical Nurse (LPN) confirmed that a gait belt is typically used for R29's transfers, and no mechanical assistance is employed. The failure to adhere to the care plan and the facility's policy on the use of gait belts during transfers constitutes a deficiency in ensuring a safe environment free from accident hazards and providing adequate supervision to prevent accidents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident, develop and implement interventions to prevent further weight loss, and ensure dietitian assessment with significant weight loss. The resident, who was alert with confusion and appeared thin and frail, had a documented significant weight loss over several months. Despite this, the resident's care plan did not include any documentation of the weight loss, risk for impaired nutrition, or interventions to prevent further weight loss. The resident's medical record also lacked documentation regarding nutrition, including dietitian assessments or recommendations since November 2023. The Assistant Director of Nursing acknowledged the significant weight loss and the lack of documentation and interventions in the resident's medical record. The Registered Dietitian confirmed that she had not been notified of the resident's weight loss since the last nutritional assessment in November 2023 and stated that different interventions should have been attempted to improve the resident's caloric and protein intake. The failure to notify the dietitian and update the care plan contributed to the ongoing weight loss in the resident.
Failure to Implement Dialysis Care Plan
Penalty
Summary
The facility failed to provide ongoing communication with the dialysis center and ensure a care plan was implemented for a resident requiring dialysis services. The resident, diagnosed with End Stage Renal Disease and dependent on renal dialysis, attended hemodialysis sessions three times a week. The resident reported that the dialysis staff were responsible for monitoring and caring for her dialysis access site, and that the facility's staff did not engage with it. The resident's care plan lacked any mention of the dialysis access site or interventions for its monitoring, care, or emergency management. Additionally, the facility could not provide records of Hemodialysis Communication Forms for several of the resident's dialysis appointments, and the Assistant Director of Nursing confirmed the absence of a care plan for the dialysis access site since the resident's admission.
Failure to Document and Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to document and monitor residents' target behaviors with the use of antipsychotic medication for two residents reviewed. Resident 8 (R8) has severely impaired cognition and a diagnosis of Dementia, and is prescribed Zyprexa for Severe Depressive Disorder. Despite the psychiatric note indicating improved behaviors, R8's medical record does not document target behaviors or monitor them every shift. The Director of Nursing confirmed that specific behavior tracking forms are not completed by staff and that target behaviors are not tracked every shift, only potentially for 14 days when starting a new psychotropic medication. Resident 52 (R52) has moderately impaired cognition with a diagnosis of Dementia and is prescribed Seroquel for Delusional Disorder. R52's medical record also lacks documentation of target behaviors for the use of the antipsychotic medication. Behavioral progress notes do not indicate any behaviors to justify the use of the medication, and observations confirmed no exhibited behaviors. The Assistant Director of Nursing stated that nurses document behaviors in progress notes but not every shift, and that Certified Nurse Aides do not document resident behaviors. R52 does not have any behaviors that justify the use of an antipsychotic medication.
Failure to Administer Medication Accurately
Penalty
Summary
The facility failed to ensure a medication to lower blood pressure was accurately administered according to the Physician's Order for one resident. The facility's Medication Administration policy and Medications Errors policy both emphasize the importance of administering medications safely and accurately as prescribed by the physician. However, during an observation, a Licensed Practical Nurse (LPN) prepared two 200 mg tablets of Labetalol for a resident, despite the physician's order specifying only one 200 mg tablet to be administered twice a day for hypertension. When questioned by the surveyor, the LPN initially confirmed that the resident takes two tablets in the morning. Upon rechecking the order, the LPN realized the mistake and removed the second tablet from the medication cup. The LPN admitted that if not prompted to recheck the order, she would have administered a double dose of Labetalol, resulting in a medication error. This incident highlights a failure in adhering to the facility's policies on medication administration and error prevention.
Failure to Apply Gloves and Implement Isolation Precautions
Penalty
Summary
The facility failed to apply gloves prior to providing high-contact care and did not ensure appropriate isolation precautions were in place for a resident (R19) with an active infection. The facility's Enhanced Barrier Precautions policy requires the use of gowns and gloves during high-contact resident care activities, such as dressing, bathing, transferring, and catheter care. Despite this, two Certified Nursing Assistants (V15 and V25) were observed transferring R19 to bed without applying gloves, even though they were wearing gowns. R19's room had a sign indicating Enhanced Barrier Precautions, but the staff did not fully adhere to the required protocols. R19 had a chronic indwelling urinary catheter and a history of chronic urinary tract infections, with a current order for an antibiotic to treat an ESBL E. coli-related urinary tract infection. The Infection Control Preventionist (V26) confirmed that R19 should have been placed under contact isolation precautions due to the active infection, which would require staff to wear gowns and gloves at all times in the room. However, this was not implemented, and the Infection Control Preventionist was unaware of the oversight due to limited presence in the facility over the past few weeks.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Macomb
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Macomb Post Acute Care Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Wesley Village | 0.3 mi | ★★★★★ | 4 | 0 |
| Countryside Care Center | 0.8 mi | ★★★★★ | 20 | 0 |
| Goldwater Care Roseville | 15.3 mi | ★★★★★ | 0 | 0 |
| Rushville Nursing & Rehab Ctr | 23.2 mi | ★★★★★ | 3 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elms, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.