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 Elmhaven East during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least eight consecutive hours on multiple occasions, as confirmed by staff postings and administrative interview. The facility also lacked a policy to guarantee this required RN coverage, affecting a census of 30 residents.
The facility did not complete the required Care Area Assessments (CAAs) as part of the comprehensive Minimum Data Set (MDS) process for several residents. Review of electronic medical records showed that, although comprehensive and quarterly MDS assessments were conducted, the triggered CAAs were not completed as required by the Resident Assessment Instrument (RAI).
A resident dependent on staff for mobility and toileting was left uncovered during peri-care, with the privacy curtain not drawn. Another staff member entered the room and spoke with the door open, making the resident visible from the hallway. Staff and administrative interviews confirmed this violated facility policy on resident dignity and privacy.
A resident with multiple serious health conditions and intact cognition was admitted to hospice care and expressed a wish to remain DNR. However, the facility failed to ensure the DNR directive was signed by the resident or representative, and inconsistencies were found in the resident's code status across records. Staff acknowledged the missing signature and the lack of a clear policy for advanced directives.
A resident with CHF on a diuretic experienced multiple significant daily weight gains, but nursing staff did not notify the physician as required by care plan and physician orders. Interviews confirmed that staff were expected to notify the physician for such changes, but no documentation of notification was found, and the facility lacked a policy for provider notification of weight changes in these cases.
A resident with multiple mental health and neurological diagnoses did not receive a required quarterly MDS assessment within the mandated timeframe. The resident, who was routinely administered antidepressant and anticonvulsant medications and exhibited moderate cognitive decline, was observed to be frequently sleeping and unresponsive. Staff confirmed the expectation for timely and accurate MDS completion, but the assessment was not performed as required.
A resident with neurogenic bladder and a Foley catheter did not have catheter care addressed in the baseline care plan upon admission. Staff observed the resident with dark red urine in the catheter bag, and administrative nurses confirmed that catheter care should have been included in the initial care plan, as required by facility policy.
A resident with a history of CVA and one-sided impairment required substantial assistance for transfers, as documented in her care plan. Staff did not consistently document the assistance needed, and during observation, two CNAs provided total assist with a gait belt, with the resident unable to bear weight and her feet not flat on the floor as required. Staff interviews confirmed inconsistency in the resident's weight-bearing ability, and the facility's ADL policy was unavailable.
Several residents with conditions such as multiple sclerosis and cerebrovascular accident did not receive restorative care or proper positioning as outlined in their care plans. Staff failed to perform or document required range of motion exercises, and one resident was observed with unsupported feet while seated in a Geri-chair. Facility policies for restorative nursing and wheelchair positioning were not followed, and staff interviews confirmed the deficiencies in care.
A resident receiving continuous oxygen therapy was repeatedly observed with oxygen tubing dragging on the floor and tangled around the wheelchair axle. Multiple staff members acknowledged that the tubing should have been secured in a pouch on the wheelchair, but the facility's policy did not address proper storage or management of oxygen equipment to prevent contamination.
A review of staffing records revealed that actual hours worked by nursing personnel were not documented on daily staffing sheets, contrary to facility policy. An administrative nurse reported being unaware of the requirement to include actual hours worked in daily postings.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours per day as required, with documented lapses on multiple dates. Review of the facility's Daily Staff Posting from 05/01/24 through 07/30/24 showed that on nine specific dates, there was no evidence of the required RN coverage. During an interview, the administrative nurse was unable to verify RN presence for the required hours on those dates. Additionally, the facility did not provide a policy ensuring RN coverage for at least eight consecutive hours every 24 hours. The facility had a reported census of 30 residents at the time of the deficiency.
Failure to Complete Required Care Area Assessments in MDS
Penalty
Summary
The facility failed to complete the comprehensive Minimum Data Set (MDS) assessments for several residents as required. Specifically, for six residents, the comprehensive MDS assessments did not include the completion of the triggered Care Area Assessments (CAAs), as mandated by the Resident Assessment Instrument (RAI). Record reviews showed that for each of these residents, both quarterly and comprehensive MDS assessments were present in the electronic medical records, but the required CAAs were missing. This deficiency was identified through review of the residents' electronic medical records and confirmed by staff interviews.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
Staff failed to maintain a resident's dignity and privacy during morning care. A resident with multiple sclerosis, who was cognitively intact but dependent on staff for bed mobility and toileting, was observed lying uncovered on her bed while staff provided peri-care. During this time, the privacy curtain was not drawn around the bed. Another staff member knocked, was told care was in progress, but still entered the room and spoke to the staff with the door open, leaving the resident visible to others in the hallway. Interviews with staff and administrative personnel confirmed that facility expectations and policy require staff not to enter a resident's room during care and to maintain privacy. The facility's policy on promoting and maintaining resident dignity specifically states that residents' rights to privacy and dignity must be protected during care. The actions observed were inconsistent with these expectations and policies.
Failure to Verify and Document Resident's DNR Directive
Penalty
Summary
The facility failed to verify and properly document a resident's advanced directives, specifically regarding a Do-Not-Resuscitate (DNR) order. The resident, who had diagnoses including Parkinson's disease, atherosclerotic heart disease, epilepsy, heart failure, and hypertension, was documented as having intact cognition and had recently started hospice care with a terminal diagnosis. The care plan indicated the resident wished to remain a DNR, but a review of the electronic health record (EHR) revealed inconsistencies: the hospice certificate listed the resident as full code, while the EHR home screen and physician orders listed the resident as DNR. The DNR directive in the EHR was signed by the physician but not by the resident or their representative, as required. Interviews with the resident confirmed her wish to be a DNR, and staff acknowledged the missing resident signature on the DNR directive. Staff also indicated that, in the event of discrepancies between DNR and full code orders, the most recent advanced directive should be honored. However, the facility did not provide a policy for advanced directives, and the lack of a resident signature on the DNR directive represented a failure to ensure the resident's wishes were properly documented and verified.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician when a resident with a diagnosis of congestive heart failure (CHF) and on a diuretic experienced significant weight gains within 24-hour periods. The resident's care plan and physician orders required daily weight monitoring due to the use of a diuretic, and the facility's records showed multiple instances where the resident gained between four and seven pounds in a single day. Despite these notable weight increases, there was no documentation that the physician was notified on any of these occasions. Interviews with nursing staff revealed that the expectation was for the nurse on duty to notify the physician of significant weight changes, particularly if there was a three-pound or greater gain in a day, even if specific parameters were not outlined in the physician's order. However, the facility did not have a policy in place regarding provider notification for weight changes in residents with CHF on diuretics. Observations of the resident showed swelling in the legs and episodes of shortness of breath, but there was no evidence that these changes prompted physician notification as required.
Failure to Complete Timely MDS Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to complete the required Minimum Data Set (MDS) assessment for a resident within the mandated timeframe. Specifically, the quarterly MDS due on 03/18/25 was not completed for a resident with multiple complex diagnoses, including schizoaffective disorder, panic disorder, seizure disorder, PTSD, anxiety, insomnia, and depressive disorder. Previous MDS assessments documented moderate cognitive decline and no depression, with the resident routinely receiving antidepressant and anticonvulsant medications. The resident's care plan included monitoring for side effects of these medications, which have Black Box Warnings, and interventions to support mental health. Observations showed the resident was frequently sleeping and unresponsive to verbal stimuli, and staff reported that she slept a lot. The administrative nurse confirmed the expectation that MDS and Care Area Assessments (CAAs) should be completed accurately and on time. The Resident Assessment Instrument (RAI) guidelines require quarterly assessments every 92 days, which was not met in this case, resulting in a failure to ensure an accurate and timely assessment for the resident.
Failure to Include Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care needs for a resident with a diagnosis of neuromuscular dysfunction of the bladder and neurogenic bladder, who was unable to bear weight and required assistance with activities of daily living. The resident's electronic medical record documented the presence of a Foley catheter with dependent drainage, initiated to manage her bladder condition and prevent skin breakdown. Despite this, the baseline care plan created upon admission did not include any documentation or instructions regarding the resident's catheter or its care, focusing only on wound assessment and pain management. Observations revealed the resident in bed with a catheter bag containing dark red urine, and staff interviews confirmed that the resident consistently had red, dark urine. Certified Medication Aides reported referencing the matrix for care information, and administrative nursing staff acknowledged that catheter care should have been included in the baseline care plan. The facility's policy required a baseline care plan to be developed and implemented within 48 hours of admission to address immediate care needs, which was not followed in this case.
Failure to Assess and Implement Proper Transfer Assistance for Resident with CVA
Penalty
Summary
The facility failed to recognize, assess, and implement appropriate interventions for a resident with a history of cerebrovascular accident (CVA) who required assistance with transfers. The resident's medical record indicated substantial to maximal assistance was needed for transfers due to impairments on one side of her body, and her care plan specified that her feet should be flat on the floor during transfers. However, staff documentation did not consistently reflect the level of assistance required, and there was no analysis of findings in the resident's Care Area Assessments (CAA). During observation, two CNAs transferred the resident using a gait belt and provided total assistance, as the resident was unable to bear weight on either leg and her feet were not flat on the floor, contrary to care plan instructions. Interviews with the CNAs revealed inconsistency in the resident's ability to bear weight, and the administrative nurse confirmed that residents should be able to bear weight during transfers. The facility's policy for activities of daily living (ADLs) was not available for review.
Failure to Provide Restorative Care and Proper Positioning for Residents with ROM Needs
Penalty
Summary
The facility failed to provide restorative care and proper positioning for multiple residents with documented needs for range of motion (ROM) and mobility support. One resident with multiple sclerosis, who was dependent on staff for transfers and wheelchair mobility and had limitations in lower extremity ROM, did not receive restorative care as outlined in her care plan. Observations showed her feet were left unsupported while seated in a Geri-chair at the dining table, contrary to facility policy and her care plan instructions. Staff interviews confirmed a lack of awareness regarding the need for foot support and acknowledged that restorative care had not been performed as required. Another resident with a history of cerebrovascular accident (CVA) and lower extremity ROM limitation was also not consistently provided with restorative care. Although her care plan specified daily active and passive ROM exercises, documentation revealed that restorative care was only provided sporadically over several months. Staff confirmed that the resident was not receiving the prescribed daily restorative care, and administrative staff acknowledged the deficiency in care delivery and documentation. A third resident with multiple sclerosis, who had no current ROM impairment but was prescribed upper extremity exercises with weights, did not receive the restorative care outlined in her care plan. The care area assessment for this resident triggered but lacked analysis, and staff interviews confirmed that restorative care was not being provided daily as required. Facility policies required maintenance and restorative services to maintain or improve residents' abilities, but these were not followed for the residents reviewed.
Failure to Prevent Oxygen Tubing Contamination
Penalty
Summary
Facility staff failed to implement proper infection control practices for a resident who was receiving continuous oxygen therapy. Multiple observations showed that the resident's oxygen tubing was repeatedly allowed to drag on the floor, become tangled around the wheelchair axle, and rest under the wheelchair in various locations throughout the facility, including the dining room and the resident's room. These observations occurred over two consecutive days and were witnessed by surveyors at different times. Interviews with facility staff, including a licensed nurse, administrative staff, and a CNA, confirmed that the oxygen tubing should not have been dragging on the floor and should have been secured in a designated pouch or pocket on the wheelchair. The facility's policy on oxygen administration did not address the proper storage and management of oxygen-delivering devices to prevent contamination or infection, contributing to the deficiency.
Failure to Post Actual Nursing Staff Hours Worked
Penalty
Summary
A review of the facility's Daily Staffing Sheets for the past 30 days showed that the actual hours worked by nursing personnel were not recorded on the daily staffing sheets. During an interview, an administrative nurse stated she was unaware that the daily staff postings were required to include the actual hours worked. The facility's policy, revised in July 2016, specifies that the actual time worked for each category of nursing personnel must be posted daily for each shift.
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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 Parsons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Parsons | 1.7 mi | ★★★★★ | 0 | 0 |
| Parsons Presbyterian Manor | 2.1 mi | ★★★★★ | 4 | 0 |
| Prairie Mission Retirement Village | 14.1 mi | ★★★★★ | 0 | 0 |
| Oswego Operator, Llc | 14.1 mi | ★★★★★ | 14 | 0 |
| Advena Living Of Cherryvale | 17.5 mi | ★★★★★ | 24 | 0 |
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