Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Elms, The during CMS and state inspections, most recent first.
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.
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 31 citations issued within 25 miles in the last 12 months — including the 1 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 | ★★★★★ | 21 | 0 |
| Goldwater Care Roseville | 15.3 mi | ★★★★★ | 4 | 1 |
| Rushville Nursing & Rehab Ctr | 23.2 mi | ★★★★★ | 1 | 0 |
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 July 2026) and official state health department websites.