Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Elwood Health And Living during CMS and state inspections, most recent first.
An LPN was observed on camera handling narcotics and medication cups in a manner that showed pills being removed from her personal backpack, kept in her hands, and placed into pockets during medication pass activities. Staff interviews and resident statements described missing narcotics, an opioid signed out at an unusual time, a resident receiving a pill that did not match his usual medication, and another resident spitting out a pink, wafer-like pill. The investigation also found the LPN took multiple items from the activities room, including lotion, jewelry, and games.
A resident with dysphagia, COPD, OSA, GERD, and post-stroke weakness was found lying flat while ordered nectar thick liquids and head-of-bed elevation were not being followed as intended because she did not have a handheld bed remote. Staff used footboard controls instead, and the resident said she often drank while lying flat and wanted a remote so she could reposition herself. Multiple observations also found no CPAP/BiPAP mask in the room, despite orders and care plan directions for respiratory support and elevated positioning.
Failure to Report Alleged Physical Abuse: A resident with hemiplegia/hemiparesis reported that staff were rough during care and that her wrist was slammed against the wall while being turned and dressed. She later had right wrist pain and x-ray findings showing compression fractures in the wrist bones. The DON did not report the allegation to the State Agency, despite facility policy requiring reporting of reasonable suspicion of crimes and investigation results.
The facility failed to provide adequate supervision and consistent fall-prevention interventions for two residents with significant mobility and cognitive impairments. One resident with severe dementia, restless leg syndrome, and repeated episodes of pacing, eyes-closed ambulation, and missed chair transfers continued to fall despite multiple care plan interventions that were not consistently in place or understood by staff. Another resident with stroke-related hemiplegia, weakness, and unsteady gait had repeated self-transfers and falls, including after a pelvic fracture and head injury, with inconsistent use of non-skid socks, alarms, and other safety measures.
Missing Narcotic Shift-to-Shift Count Documentation: Surveyors found missing signatures on the Narcotic Shift to Shift Count Record for 4 of 5 medication carts reviewed, including the 100-, 200-, and 300-hall carts. RN 14, LPN 5, RN 9, and the DON acknowledged that the narcotics count should be signed every shift by both the oncoming and off-going nurse, but multiple shifts were left undocumented.
Medication Error Rate Exceeded 5 Percent: During medication pass observations, an LPN left polyethylene glycol 3350 mixed with water on two residents’ tables after they drank only part of the dose, rather than observing complete ingestion. One resident was severely cognitively impaired and the other was moderately cognitively impaired. Staff interviews and facility policy confirmed the medication was not to be left unattended, and the observed errors resulted in a 6.9% medication error rate.
Loose medications were found in two medication carts during observations with nursing staff. An RN found a blue oblong pill loose in the 200-hall cart, and an LPN found multiple loose pills and capsules in the 300-hall cart, including several different imprinted tablets and capsules. The DON stated cart audits were performed and that unit managers cleaned out the carts weekly, while facility policy required timely disposal of medications without secure closure, outdated, contaminated, or deteriorated.
A resident with severe cognitive impairment, dysphagia, lack of coordination, and vision-related dining needs had an order and care plan for a red plate at meals, but dining observations showed meals served on a standard white plate instead. Staff interviews showed confusion about who needed the red plate, CNAs were not aware of the need, and dietary staff relied on preference rather than consistently providing the ordered adaptive equipment.
A resident with an indwelling urinary catheter had a drainage bag repeatedly hanging under the wheelchair and resting on or dragging across the floor, and staff confirmed the bag should not touch the floor because of infection control issues. In a separate event, staff provided perineal care and wound care to a resident on EBP for a feeding tube while wearing gloves but not gowns, despite signage requiring gloves and gowns for high-contact care such as hygiene, changing briefs, and wound care.
A cognitively impaired resident with a history of exit-seeking behaviors and identified as an elopement risk was able to leave a secured unit unsupervised on two occasions. The resident was found outside the secured area near the parking lot without staff supervision, despite interventions and reminders to staff and visitors to keep doors secure. Security footage confirmed the resident was outside for several minutes before being returned by a CNA, indicating a failure to provide adequate supervision and prevent accident hazards.
The facility failed to maintain comfortable water temperatures for residents in the 300 Hall, with several residents experiencing consistently cold or lukewarm water in their bathroom sinks. Despite weekly audits showing adequate temperatures, the logs did not indicate the time taken to reach these temperatures. Staff and residents reported ongoing issues, and the facility lacked a policy on hot water conditions.
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by unresolved maintenance issues. A resident with mobility issues experienced a fall due to a loose bathroom countertop, which had not been replaced despite a maintenance request. Another resident reported damage to her room's walls that had been unaddressed for months, and a third resident's window sill had a significant hole covered with peeling tape. The facility lacked a policy for environmental maintenance, contributing to these deficiencies.
The facility failed to ensure residents with dementia did not receive antipsychotic medications without proper indication and individualized interventions. A resident with severe cognitive impairment exhibited various behaviors, yet their care plan lacked adequate interventions, and quetiapine was used without clear necessity. Another resident received quetiapine despite assessments showing no delusions or hallucinations. Staff reported challenges in managing behaviors, but care plans did not reflect a comprehensive approach, leading to a deficiency in dementia care.
A resident with a history of anxiety and dementia was prescribed quetiapine, an antipsychotic, without clear indication of a psychotic disorder. The resident exhibited behaviors related to pain and anxiety, but no psychotic symptoms were documented. The facility's policy required medications to be prescribed only for specific diagnosed conditions, which was not followed, leading to inappropriate medication use.
The facility failed to implement proper transmission-based precautions for two residents with COVID-19. A resident's COTA exited the room without the required N-95 mask and protective eyewear, citing vision issues. Another resident's Activities Assistant entered the room without gloves and goggles, admitting to forgetting them. Staff interviews confirmed the facility's policy required full PPE, including gowns, N-95 masks, gloves, and protective eyewear.
A resident with ALS and severe migraines had unauthorized access to Imitrex stored in a lock-box in her room, with the key hidden and known to family and nurses. The facility's policy requiring medication storage access to be limited to authorized personnel was not followed.
The facility failed to identify and properly treat pressure injuries for two residents, leading to deficiencies in care. One resident's pressure injury progressed to a stage 3 wound due to inconsistent wound care practices, while another resident's dressing was not changed as required, resulting in inadequate wound monitoring.
A resident frequently incontinent of bowel and bladder received improper perineal care from a CNA, who washed the resident's labia from back to front instead of the correct front to back method. This error was confirmed by both an RN and the DON. The resident, diagnosed with type 2 diabetes mellitus, was subsequently treated for a UTI.
The facility failed to properly administer medications, resulting in a 7.69% error rate. Two residents received insulin from expired vials, contrary to facility guidelines and policies. Interviews confirmed the use of expired insulin, compromising proper medication administration.
A resident reported being called a derogatory name by a CNA, which caused emotional distress. The incident involved the resident being called a 'f---ing heifer' after requesting assistance. Interviews revealed differing accounts, but the term 'heifer' was consistently mentioned. The facility's policy on resident dignity was not followed, leading to the resident feeling disrespected.
The facility failed to thoroughly investigate an injury of unknown origin for a resident with multiple medical conditions, including Alzheimer's and vascular dementia. The resident was found with a bruise and dry skin area on the right heel, which later was diagnosed as an acute avulsion fracture. The investigation lacked essential components such as staff interviews and assessments.
The facility failed to investigate a fall resulting in a fracture for a resident with dementia, repeated falls, and osteoarthritis. Despite having a care plan, the intervention was only more frequent rounding. The resident sustained an unwitnessed fall, resulting in an acute right femoral neck fracture. The investigation was inadequate, lacking staff interviews, assessments, and education.
Misappropriation of Resident Medications and Property
Penalty
Summary
The facility failed to protect residents from the wrongful use of their medications and other property after an investigation into an unusual narcotic count and camera footage showed an LPN handling medications in a manner inconsistent with normal medication administration. During the shift-to-shift count, the narcotic count was off by one pill, and the LPN stated she had left a pill in a cup in the medication room. Camera footage reviewed by the DON and Administrator showed the LPN entering the medication room, reaching into her personal backpack, removing a plastic bag of pills, and handling medication cups and narcotic cards while repeatedly placing her hands into her pockets and keeping pills concealed in her hands. The footage also showed her moving medication cups between carts and drawers while appearing to retain pills in her hands and pockets. The investigation included interviews with staff and residents and showed concerns involving medications for multiple residents. Staff reported that the LPN said she had "double popped" a narcotic for one resident and had gone into the medication room to retrieve it after the count was found to be off. The narcotic sign-out record showed that an opioid pain medication for that resident had been signed out at 4:30 a.m., although the resident routinely received the medication daily at 8:00 a.m. The resident’s record showed diagnoses including neuropathy, spondylosis, and lumbar disc displacement, and the resident was cognitively intact. Another resident’s record showed diagnoses including chronic pain and polyneuropathy, with orders for oxycodone-acetaminophen as both scheduled and PRN medication; that resident denied needing pain medication, and the medication administration sheet lacked documentation of a PRN dose at the time in question. Resident interviews also described medication discrepancies. One cognitively intact resident reported that an LPN first brought medications that did not look like his usual medications, then returned with the correct ones. Later, he was given a scheduled medication in a dark room, and the pill appeared pink and wafer-like rather than like his usual medication; he spit it out and later gave it to the day shift nurse. The resident stated the LPN later told him the medication would not have hurt him and that it was just a vitamin. The facility’s investigation concluded that the LPN had taken multiple medications through the shift, and the report also stated that she was observed taking items such as lotion, jewelry, and games from the activities room and placing them in a filing cabinet and later in her backpack.
Failure to Provide Ordered Bed Positioning and Respiratory Equipment Access
Penalty
Summary
The facility failed to provide accommodations for a resident with dysphagia, COPD, OSA, GERD, and hemiplegia/hemiparesis after a stroke by not ensuring access to a handheld bed remote and not consistently having the resident’s CPAP/BiPAP mask available in the room. The resident’s care plan and physician orders directed that the head of bed be elevated for breathing comfort and that nectar thick liquids be given while upright, with no straws and small sips. During observation, the resident was found lying flat in bed with the head of bed not elevated, and a cup with a lid and straw was present on the bedside table. The resident stated she was unable to elevate the head of the bed because she did not have a handheld remote and said she often drank fluids while lying flat. Observations on multiple dates showed the head of bed remained below the ordered position and that no CPAP mask was present in the resident’s room. Staff interviews confirmed the bed was controlled by buttons on the footboard rather than a handheld remote, and several staff stated they had never seen a handheld remote on the bed. The resident stated she wanted a bed remote so she could use it accordingly, and LPN staff acknowledged that if the resident wanted the head of bed elevated to drink liquids, staff had to do it for her. The Unit Manager and DON both stated they were not aware the resident did not have a handheld bed remote, and the Nurse Consultant stated the resident was to have one and that not having it could put the resident at risk for complications. The resident’s record showed intact cognition, dependence for rolling left and right, and a mechanically altered diet with nectar thick liquids. Care plans directed BIPAP as ordered and head of bed elevation for shortness of breath, as well as serving the ordered mechanically soft, ground meat, nectar thick diet. The facility did not have a policy pertaining to bed remotes or accommodation of needs. The deficiency was based on the facility’s failure to provide the resident access to the equipment and positioning support identified in her plan of care and physician orders.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported to the State Agency for 1 of 1 residents reviewed for abuse. Resident 5 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. On 2/15/26, the resident told the nurse that someone was really rough during care, that her wrist got slammed on the wall, and that the aides were in a rush and not paying attention. The resident continued to complain of right wrist pain, and an x-ray was ordered. An acute care note the next day documented the resident’s report that nursing staff had been really rough while changing her and that her wrist got slammed against the wall; she also described her arm falling off the bed and bending backward during turning. A follow-up note documented that the right wrist x-ray showed a complete compression fracture of the lunate bone and a partial compression fracture of the scaphoid bone, with a prior 11/2022 x-ray showing a similar abnormal appearance of the lunate bone. During interviews, the DON stated she remembered the incident was on a weekend but did not remember the details, and after interviewing the resident, the DON did not report the incident to the State Agency. The RNC stated the resident was not a reliable witness. Written statements from CNA 22 and CNA 23 described getting the resident dressed and moving the bed away from the wall, and CNA 23 stated the resident complained of right wrist pain and said someone was too rough. The facility policy required reporting reasonable suspicion of crimes against residents and reporting the results of investigations to the State Survey Agency within five working days.
Failure to Prevent Recurrent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide supervision and to develop and implement effective interventions to prevent recurrent falls for two residents. One resident had diagnoses including severe dementia, difficulty walking, low back pain, restless leg syndrome, and hypertension, and was documented as severely cognitively impaired. He was ambulatory and had a long history of falls, with multiple episodes of walking with his eyes closed, pacing, attempting to sit and missing chairs, and being found on the floor beside his bed or in common areas. His care plan listed numerous fall-related interventions, including gripper socks, a fall mat, a mattress on the floor, a weighted blanket, and a pool noodle bolster, but observations showed some of these interventions were not in place or were not being used as ordered. The resident continued to fall repeatedly despite the documented interventions. Progress notes described him being found on the floor, walking into walls and furniture, falling while trying to sit, and being found kneeling or sitting on the floor beside his bed. Staff and the resident’s representative reported that he was restless, often ambulated with his eyes closed, and could not remain in bed. During later observations, the mattress was propped against the bed, the pool noodle was not being used, and wheelchairs were left in the hallway and were not locked. Staff interviews showed confusion about the mattress order and the pool noodle, and the DON stated staff should have been following the care planned interventions. A second resident with stroke-related hemiplegia, dysphasia, weakness, unsteadiness, and need for assistance with personal care also had repeated falls and unsafe self-transfers. His record showed falls related to getting up without assistance, sliding from bed, reaching for items, and falling from his wheelchair. The record also showed a pelvic fracture after one fall, but the clinical record lacked updated individualized fall prevention interventions after that injury and after another head injury fall. The resident’s care plan and notes reflected inconsistent use of safety measures such as non-skid socks, bed positioning, and personal alarms, and staff interviews indicated alarms were sometimes not turned back on after battery replacement, beds may not have been locked, and interventions were not consistently followed.
Missing Narcotic Shift-to-Shift Count Documentation
Penalty
Summary
The facility failed to ensure the narcotic shift-to-shift count was completed and documented for 4 of 5 medication carts reviewed. During medication cart observations, surveyors found multiple missing signatures on the Narcotic Shift to Shift Count Record for the 200-hall back cart, the 200-hall front cart, the 300-hall back cart, and the 100-hall cart. The missing entries involved both oncoming and off-going nurses across multiple shifts, including several dates where signatures were absent for required count documentation. During the observations, RN 14, LPN 5, and RN 9 each acknowledged that the Narcotic Shift to Shift Count Record was missing signatures and stated that the count should be signed every shift by the oncoming and off-going nurse. In an interview, the DON stated that narcotics should be counted and the shift-to-shift count should be signed every shift, but that nurses and QMAs sometimes sign on and do not sign off because QMAs work 8-hour shifts and nurses work 12-hour shifts. A facility policy titled Medication Administration General Guidelines stated that staff should not report off shift without ensuring documentation is complete.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent during medication pass observations for 2 of 5 residents, with 29 opportunities for error and 2 medication errors, resulting in a 6.9 percent error rate. During observation, an LPN prepared Resident 27’s medications and brought the pills into the room with an 8-ounce cup of water mixed with 17 grams of polyethylene glycol 3350 for constipation. The resident drank about four ounces, and the LPN left the remainder of the medicated water mix on the resident’s table, stating she would check back later. Resident 27’s record showed diagnoses including constipation and a quarterly MDS indicating severe cognitive impairment, and the order for polyethylene glycol 3350 did not include self-administration of medications. A similar event occurred with Resident 22, whose LPN prepared medications and brought them into the room with an 8-ounce cup of water mixed with 17 grams of polyethylene glycol 3350. The resident drank approximately two ounces, and the LPN left the remainder on the resident’s table, stating she would check back later. Resident 22’s record showed a diagnosis of constipation, a quarterly MDS indicating moderate cognitive impairment, and a care plan addressing constipation with interventions to administer medications as ordered. Staff interviews and the DON confirmed that polyethylene glycol 3350 mixed with water was not to be left unattended in residents’ rooms and that nurses were to observe residents taking their medications. The facility policy also stated that licensed nurses or authorized personnel must stay with the resident to ensure medications are completely ingested.
Loose Medications Found in Medication Cart Drawers
Penalty
Summary
The facility failed to ensure medications were stored in a manner that prevented loose pills from being present in medication cart drawers. During an observation of the 200-hall medication cart with an RN, a blue oblong pill inscribed with A-17 was found loose in the second drawer on the left side of the cart. The RN stated the pill should have been destroyed in a drug buster, and the medication carts were cleaned out weekly. During a separate observation of the 300-hall medication cart with an LPN, multiple loose pills and capsules were found in the third drawer from the top, including a peach capsule inscribed with 215, a pink round pill inscribed with 262, a white round pill inscribed with HP 23, a green oblong pill inscribed with E 45, a pink and orange pill inscribed with EP 102, a white round pill inscribed with L 150, and a pink oblong pill inscribed with 894. The DON later stated the facility performed medication cart audits and that it was unusual to have loose pills in the carts, and that unit managers cleaned out the carts once a week. The facility policy on Medication Cart Supplier and Maintenance stated that disposal of medications should be completed for medications that are without secure closure, outdated, contaminated, and/or deteriorated, and that disposal needed to be timely.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive tableware for 1 of 2 residents reviewed for assistive devices used during dining. Resident 16 had diagnoses including need for assistance with personal care, dysphagia at the oropharyngeal stage, lack of coordination, and dry eye syndrome. His current orders included a regular diet with thin liquids and a red plate at meals, and his care plan also identified a red plate for meals related to vision issues. An annual MDS assessment indicated severe cognitive impairment and that he required supervision or touching assistance with eating. During dining observations, Resident 16’s meals were served on a white plate rather than the ordered red plate. Staff interviews showed that nursing relayed specialty dining items verbally to dietary staff and completed a form, but CNAs were not typically aware of who needed red plates and the need was not on assignment sheets. The Dietary Manager and other staff gave conflicting information about whether Resident 16 was receiving a red plate, and a CNA confirmed that his lunch was served on a standard white plate with no red plates available in the cart. The DON stated the red plate intervention was care planned and identified on the meal ticket, but dietary staff relied on preference and did not consistently serve the resident on the red plate.
Infection Control Failures With Catheter Bag Handling and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to use infection prevention and control strategies for a resident with an indwelling urinary catheter when the urinary drainage bag repeatedly hung below the wheelchair and rested on or dragged across the floor. Resident 65 had diagnoses including obstructive and reflux uropathy and dementia, used a wheelchair for mobility, and was dependent on staff for toileting, personal hygiene, and transfers. The resident had an order for the urinary drainage bag to be changed weekly, and the care plan included keeping the catheter tubing and bag below the level of the bladder. During multiple observations, the drainage bag was seen hanging under the wheelchair, touching the floor, and dragging on the floor as the resident self-propelled in the hallway. On one occasion, the bag was dated 3/1 and rested on the floor while the resident sat in the wheelchair in his room. Staff later confirmed the bag was on the floor and stated it should never touch the floor because of infection control issues. The DON also stated the catheter drainage bag was not to touch the floor, ever, and that touching the floor was an infection control issue. The facility also failed to ensure enhanced barrier precautions were used during perineal care and wound care for a resident with a feeding tube. Resident 56 had diagnoses including dysphagia and cervical spinal cord injury, was dependent on staff for all activities of daily living, and had an order for EBP when caring for the feeding tube. During observation, staff performed incontinence care and wound care while wearing gloves but not gowns, despite a door sign stating that gloves and gowns were required for high-contact care activities including changing briefs, providing hygiene, and wound care. Staff later stated they had not worn gowns during the care, and the DON stated staff would be expected to apply PPE for high-contact care on residents on EBP.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including anxiety, depression, vascular dementia with behaviors, and stage 3 chronic kidney disease was identified as being at risk for elopement, as documented in their care plan and elopement risk assessment. The resident resided on a secured unit and had a history of exit-seeking behaviors, such as shaking and pushing at doors. Despite interventions in place, the resident was able to leave the secured unit unsupervised on two occasions. On one occasion, the resident was found wandering outside the secured courtyard fence, near the parking lot, without staff supervision. It was not clear how long the resident had been outside before being found by a CNA who was on break. Interviews with facility staff revealed that the doors on the unit were supposed to be secure, and staff and visitors were reminded to ensure doors were closed tightly and to prevent residents from following them off the unit. However, during an activity in the courtyard, the resident was able to exit the secured area and was later found outside the building. Security video confirmed the resident exited the building and was outside for less than three minutes before being brought back inside by a CNA. The incident demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards for a resident at risk for elopement.
Failure to Maintain Comfortable Water Temperatures
Penalty
Summary
The facility failed to maintain water temperatures at a comfortable level for residents in the 300 Hall, affecting four out of seven residents reviewed. Observations revealed that the hot water in several rooms' bathroom sinks did not reach a comfortable temperature, with some only reaching lukewarm levels even after running for several minutes. Residents C and E reported consistently cold water in their bathroom sinks, with Resident E noting the issue had persisted for 3-4 months. Staff interviews corroborated these complaints, indicating that residents had been experiencing cold water issues, particularly further down the 300 Hall. The Maintenance Supervisor confirmed that residents had complained about the lack of hot water and noted that it could take several minutes for the water to reach over 100 degrees Fahrenheit. Despite weekly water temperature audits showing temperatures above 100 degrees Fahrenheit, these logs did not specify how long the water had to run to reach those temperatures. During a follow-up observation, water temperatures in some rooms still failed to reach comfortable levels even after extended periods. The Maintenance Supervisor mentioned discussions with a plumber about adding a recirculating pump to improve hot water circulation. The facility lacked a policy regarding environmental conditions and hot water, contributing to the deficiency.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe and comfortable environment for several residents, as evidenced by the conditions observed in their living spaces. Resident D, who has type 2 diabetes mellitus, chronic kidney disease, muscle weakness, and abnormality of gait and mobility, experienced issues with a loose bathroom countertop that she used for balance during transfers. Despite a maintenance request being submitted, the countertop had not been replaced, and Resident D reported a fall incident where she used the unstable countertop to assist herself. The Maintenance Supervisor acknowledged having the replacement countertop but had not yet installed it due to time constraints. Resident C reported missing paint and damage to the drywall in her room caused by the bed frame scraping against the wall. Despite her complaints to the maintenance department, the issue had persisted for four months without resolution. Additionally, Resident 42's window sill had a significant hole covered with peeling plastic and paper tape, which had been present since January 2025. The Maintenance Supervisor was only recently informed of this issue and had not yet addressed it. The facility lacked a policy regarding environmental maintenance, contributing to these unresolved deficiencies.
Inappropriate Use of Antipsychotic Medications in Dementia Care
Penalty
Summary
The facility failed to ensure that residents with dementia did not receive antipsychotic medications without proper indication and individualized interventions for behavioral expressions. Resident 33, who was severely cognitively impaired, was observed to have a history of various behaviors such as urinating in inappropriate places, aggression towards staff, and wandering into other residents' rooms. Despite these behaviors, the resident's care plan did not adequately address the need for individualized interventions, and the use of quetiapine fumarate was continued without clear documentation of its necessity, as the resident did not exhibit hallucinations or delusions during assessment periods. Resident 61, diagnosed with dementia and other mental health conditions, was also administered quetiapine fumarate for hallucinations, delusions, and paranoia. However, the resident's assessments indicated that he was cognitively intact or moderately impaired without delusions or hallucinations during the assessment periods. The care plans for Resident 61 included interventions for anxiety and wandering but did not provide sufficient evidence for the use of antipsychotic medication, raising concerns about the appropriateness of the medication regimen. The observations and interviews with staff highlighted a lack of consistent and effective interventions tailored to the residents' specific needs. Staff members reported challenges in managing the residents' behaviors, such as aggression during care and wandering, but the care plans did not reflect a comprehensive approach to address these issues. The facility's failure to implement individualized interventions and the inappropriate use of antipsychotic medications contributed to the deficiency in dementia care for these residents.
Inappropriate Use of Antipsychotic Medication Without Indication
Penalty
Summary
The facility failed to ensure that an antipsychotic medication was not initiated without proper indication for a resident. The resident, who had a history of generalized anxiety disorder, alcohol dependence in remission, hypertension, and unspecified dementia, was prescribed quetiapine fumarate, an antipsychotic medication, without a clear indication of a psychotic disorder. The resident's care plans and clinical records indicated various diagnoses, including anxiety, depression, and insomnia, but there was no documented evidence of hallucinations or delusions that would necessitate the use of an antipsychotic. Observations and interviews with staff revealed that the resident frequently complained of pain and exhibited behaviors such as crying, yelling, and expressing a desire to die, often related to pain or when requesting more pain medication. Despite these behaviors, there was no documentation of psychotic symptoms such as hearing voices or seeing things that were not there. The facility's policy on psychotropic medication management emphasized the need for medications to be prescribed only when necessary to treat a specific diagnosed and documented condition, which was not adhered to in this case. The facility's failure to document a clinical indication for the use of quetiapine in the resident's medical record, as required by their policy, led to the deficiency. The resident's behaviors were primarily related to pain and anxiety, and non-pharmacological interventions were not adequately explored or documented as alternatives to the antipsychotic medication. This oversight in medication management and documentation resulted in the inappropriate use of a psychotropic medication, contrary to the facility's policy and regulatory requirements.
Failure to Implement Transmission-Based Precautions for COVID-19
Penalty
Summary
The facility failed to ensure proper implementation of transmission-based precautions for two residents diagnosed with COVID-19. Resident 62, who had a history of osteomyelitis, cerebral infarction, and cognitive communication deficit, was placed on droplet precautions as per physician orders. However, a Certified Occupational Therapy Assistant (COTA) was observed exiting the resident's room wearing only a surgical mask and personal glasses, without the required N-95 mask and protective eyewear. The COTA admitted to not using goggles over her glasses due to vision issues. Similarly, Resident D, who had conditions including hypothyroidism and chronic heart failure, was also on droplet precautions. An Activities Assistant entered Resident D's room wearing a gown and surgical mask but failed to don gloves and protective eyewear. The assistant acknowledged forgetting to wear goggles. Interviews with various staff members, including a Certified Nursing Assistant Coordinator and an LPN, confirmed that the facility's policy required staff to wear a gown, N-95 mask, gloves, and protective eyewear when entering the room of a resident with COVID-19, even if they wore glasses.
Unauthorized Access to Medication in Resident's Room
Penalty
Summary
The facility failed to limit medication access to authorized personnel for a resident, identified as Resident B, who was reviewed for medication storage. During an observation, it was revealed that Resident B had a syringe of Imitrex, an injectable migraine medication, stored in a lock-box in her room. The lock-box was accessible via a key hidden in the room, which was known to the resident's family and all nurses. The Director of Nursing (DON) and the Administrator were unaware of the lock-box and the hidden key, which was contrary to the facility's policy that required medications to be stored in locked compartments with access limited to authorized personnel. Resident B had a medical history that included Amyotrophic Lateral Sclerosis (ALS), dysphagia, depression, anxiety, and severe migraines. The resident's family had been bringing in Imitrex because they believed the generic version provided by the facility was ineffective. The family member would place the medication in the lock-box and return the key to its hiding place. The facility's policy required that all medications be stored in a locked storage area with access limited to authorized personnel, which was not adhered to in this case.
Failure to Identify and Treat Pressure Injuries
Penalty
Summary
The facility failed to identify and properly treat pressure injuries for two residents, leading to deficiencies in care. Resident 115, who had multiple diagnoses including type 2 diabetes mellitus and muscle weakness, was observed to have a painful sore on her bottom. Despite being cognitively intact and dependent on staff for various activities, the resident's pressure injury was not identified promptly, and the appropriate wound care was not implemented. The wound, which was initially identified as moisture-associated skin damage (MASD), progressed to a stage 3 pressure injury with rolled edges, indicating it had been present longer than initially thought. Interviews with staff revealed inconsistencies in wound care practices and a lack of thorough assessment, contributing to the worsening of the resident's condition. Resident 24, who was severely cognitively impaired and dependent on staff for daily activities, was observed lying in the same position over multiple days, increasing the risk of pressure ulcers. The resident had a physician's order for a foam dressing to be applied to a stage 1 pressure wound on the left ankle. However, the dressing was not changed as required, and the wound was not properly monitored. The DON discovered that the order for the foam dressing had been incorrectly entered into the clinical record, resulting in the dressing not being changed since the order was placed. This oversight was not caught during daily preventative skin assessments, leading to inadequate wound care for the resident. The facility's policy on wound care was not followed, as nursing staff failed to employ preventative measures and properly document and treat identified wounds. The lack of adherence to the wound care program and the failure to perform thorough skin assessments and timely interventions contributed to the deficiencies in care for both residents. Interviews with staff highlighted gaps in communication and documentation, which further exacerbated the issues with wound management and treatment.
Improper Incontinence Care Leading to UTI
Penalty
Summary
The facility failed to provide incontinence care in a hygienic manner for Resident 115, who was frequently incontinent of bowel and bladder and required substantial assistance for personal care. During an observation of perineal care, a CNA washed the resident's labia from back to front, which is contrary to the facility's policy of washing from front to back. This incorrect technique was repeated with another washcloth for rinsing. The CNA later acknowledged the mistake, attributing it to her position relative to the resident. Both an RN and the DON confirmed the improper technique during subsequent interviews. Resident 115's medical records indicated a diagnosis of type 2 diabetes mellitus and a need for assistance with personal care. The resident had a physician's order for a urinalysis and culture due to dysuria and altered mental status, and was subsequently prescribed an antibiotic for a UTI. The facility's policy on perineal care, revised in 2019, clearly stated the correct procedure for washing, rinsing, and drying the perineal area from front to back, which was not followed in this instance.
Medication Administration Errors Due to Expired Insulin Vials
Penalty
Summary
The facility failed to properly administer medications as ordered by the physician, resulting in a medication administration error rate of 7.69%. During an observation, QMA 5 administered insulin to two residents using vials that were past their expiration date. Specifically, Resident 31 received 2 units of Insulin Aspart, and Resident 50 received 1 unit of NovoLOG, both from vials that were opened more than 28 days prior. The facility's guidelines and policies clearly state that insulin vials should not be used beyond 28 days after opening. Interviews with QMA 5 and the DON confirmed that the insulin vials used were expired, and the facility's Product Expiration Dates guidelines were not followed. The clinical records for both residents indicated that the insulin was to be administered according to a sliding scale, but the expired insulin vials compromised the proper administration of these medications. The facility's policy on insulin preparation and administration was not adhered to, leading to these medication errors.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure staff treated a resident with respect and dignity, as evidenced by an incident involving Resident B. Resident B, who has diagnoses including morbid obesity, anxiety disorder, and depression, reported that a CNA called her a derogatory name that hurt her feelings. The incident occurred when Resident B had her call light on for assistance, and a nurse provided her with a pain pill and incontinence care. Subsequently, CNA 21 entered the room and called Resident B a 'f---ing heifer,' which deeply upset her. Resident B expressed that she struggled with her weight and found the term 'heifer' particularly hurtful. She reported the incident to another CNA, who felt it was abusive but did not report it immediately, leading to a delay in addressing the issue. Interviews with various staff members revealed differing accounts of the incident. CNA 34 confirmed that Resident B was upset and had reported the incident to her, but she did not report it immediately. CNA 21 admitted to calling Resident B a 'heifer' but denied using the explicit language. She claimed it was a term she used jokingly and did not intend to hurt Resident B's feelings. The Social Service Director noted that Resident B's account of the incident changed slightly each time she retold it, but it consistently involved being called a 'heifer.' The Administrator confirmed that the incident was reported around 1:30 p.m., and Resident B was visibly upset about being called a 'heifer,' focusing on her weight loss struggles. The facility's policy on promoting and maintaining resident dignity, dated 4/1/19, emphasizes the importance of speaking respectfully to residents. The failure to adhere to this policy resulted in Resident B feeling disrespected and emotionally distressed. The incident highlights a lapse in the facility's adherence to its own guidelines for treating residents with dignity and respect.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury of unknown origin for Resident B, who had a fracture in the right heel. Resident B's medical history includes conditions such as restless leg syndrome, osteoarthritis, cerebral aneurysm, transient cerebral ischemic attack, dysphagia, psychotic disorder with hallucinations, type 2 diabetes with diabetic neuropathy, anxiety, delusions, Alzheimer's Disease, and vascular dementia. The resident required extensive assistance for bed mobility and transfers and was severely cognitively impaired. On 1/2/24, LPN 1 observed a bruise and dry skin area on Resident B's right heel, which was bleeding. The nurse applied skin prep and a dressing but did not notify the physician. Later, an x-ray revealed an acute avulsion fracture of the heel bone. The facility's investigation lacked essential components such as staff interviews, assessments, and interviews of other residents, or staff education. During an interview, the Director of Nursing (DON) and Administrator indicated that the facility did not have any further information related to the investigation. The current CDC guidance for investigations requires thorough evidence collection, including observations, interviews, and record reviews, which the facility failed to meet. This citation relates to Complaints IN00426284 and IN00425232.
Failure to Investigate Fall Resulting in Fracture
Penalty
Summary
The facility failed to investigate a fall resulting in a fracture for Resident C, who had diagnoses including dementia, repeated falls, and osteoarthritis. The resident required touch assistance for walking and partial moderate assistance for transfers and was severely cognitively impaired. Despite having a care plan for falls, the intervention for the fall on 12/26/23 was only more frequent rounding. On 1/16/24, Resident C sustained an unwitnessed fall and was found sitting on the bathroom floor. Initially, no injuries were found, but later the resident complained of left hip pain, and an x-ray revealed an acute right femoral neck fracture. The resident was sent to the hospital, and the family declined surgical interventions. The facility's investigation into the fall was inadequate, lacking staff interviews, assessments, and interviews of other residents, or staff education. During an interview, the DON and Administrator confirmed that no further information was available related to the investigation. The report references training from the Agency for Healthcare Research and Quality, which emphasizes the importance of investigating the circumstances of a fall, including individual risk factors, environmental factors, and factors in care or equipment, and documenting the findings. This citation relates to Complaints IN00426284 and IN00425232.
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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 Elwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alexandria Care Center | 9.3 mi | ★★★★★ | 1 | 0 |
| Waters Of Tipton Skilled Nursing Facility, The | 10.5 mi | ★★★★★ | 19 | 0 |
| Summit Health And Living | 11.2 mi | ★★★★★ | 9 | 0 |
| Northview Health And Living | 12.4 mi | ★★★★★ | 20 | 0 |
| Edgewater Woods | 12.6 mi | ★★★★★ | 6 | 0 |
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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.