Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmhurst Healthcare (the) during CMS and state inspections, most recent first.
A resident's preference for a urinary catheter drainage bag was not honored, despite being cognitively intact and having it documented in their care plan. The resident was observed wearing a leg bag, which they found uncomfortable. Staff interviews revealed communication lapses, with a CNA noting restricted access to the preferred bags and a nurse failing to verify the change. The facility's administration acknowledged awareness of the resident's preference, highlighting a failure to adhere to the care plan.
A facility failed to properly manage a resident's urinary catheter, resulting in the drainage bag touching the floor and the use of a leg bag above bladder level while in bed. Staff interviews revealed a lack of adherence to policies, with CNA and nurse failing to empty or change the bag as required. The resident expressed dissatisfaction with the leg bag, which filled up quickly and was not emptied overnight.
The facility failed to maintain accurate medical records for three residents, leading to incomplete documentation of ADLs across multiple shifts. A resident with vertigo had significant gaps in documentation, including dressing and fluid intake. Another resident with end-stage renal disease had missing records for all night shifts, while a third resident with bladder cancer had incomplete documentation in areas like bathing and personal hygiene. The Nursing Supervisor and Administrator acknowledged the ongoing issue of missing documentation.
The facility failed to maintain an effective infection prevention and control program, as healthcare personnel did not adhere to proper glove removal and hand hygiene protocols. CNAs were observed exiting resident rooms without removing gloves or performing hand hygiene, and one CNA did not wear a precaution gown while providing care to a resident on Enhanced Barrier Precautions. Interviews confirmed the necessity of these practices, but the facility lacked a specific policy on Enhanced Barrier Precautions.
Failure to Honor Resident's Preference for Urinary Catheter Bag
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's preference for a urinary catheter drainage bag instead of a leg bag. The resident, who was cognitively intact and had a suprapubic catheter, expressed a preference for a larger drainage bag that hangs from the side of the bed, as documented in their care plan. However, during observations, the resident was found wearing a leg bag, which they found uncomfortable and inconvenient due to its small capacity. Interviews with staff revealed a lack of communication and follow-through regarding the resident's preference. A CNA noted that the larger drainage bags were locked away, and only nurses had access to them. The assigned nurse assumed the previous shift had made the change but did not verify this. The facility's administrator and DON acknowledged that the staff had been informed of the resident's preference and that it was part of the care plan, indicating a failure to adhere to the resident's rights and care plan directives.
Deficiency in Urinary Catheter Management
Penalty
Summary
The facility failed to maintain professional standards in managing and caring for urinary catheter devices for Resident #18. The resident, who was cognitively intact and required an indwelling urinary catheter, was observed with a urinary catheter drainage bag hanging from the side of the bed and directly touching the floor, which is against the facility's policy. Additionally, the resident was found wearing a urinary catheter leg bag while in bed, with the bag positioned above the level of the bladder, contrary to the care plan that required the drainage bag to be below bladder level. The resident expressed dissatisfaction with the leg bag, stating it filled up too quickly and had not been emptied since the previous night. Interviews with staff revealed a lack of adherence to the facility's policies and procedures. CNA #1 admitted to not emptying the leg bag during her shift and noted that the larger drainage bags were locked away, accessible only to nurses. Nurse #1 acknowledged not checking or emptying the drainage bag during his shift, assuming the previous nurse had made the necessary changes. The Director of Nursing confirmed that the resident should not have been using a leg bag while in bed and that drainage bags should not touch the floor. These lapses in care and communication among staff contributed to the deficiency in catheter management for Resident #18.
Incomplete ADL Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, resulting in incomplete documentation of Activities of Daily Living (ADL) across multiple shifts. Resident #275, admitted with vertigo, had significant gaps in documentation for various ADL categories, including dressing, bathing, and fluid intake, among others. The records showed that 53 out of 88 opportunities for turn and positioning documentation were left blank. Interviews with the Nursing Supervisor and Administrator revealed that incomplete documentation has been an ongoing issue, with staff expected to document all care provided before leaving their shifts. Resident #225, diagnosed with end-stage renal disease, also had missing documentation for all night shifts in July, failing to record essential ADL activities such as bed mobility and bladder or bowel continence. Similarly, Resident #226, with a diagnosis of bladder cancer, had numerous shifts with incomplete documentation, particularly in areas like bathing, dressing, and personal hygiene. The Nursing Supervisor and Administrator acknowledged the persistent problem of missing documentation, emphasizing the expectation for nursing assistants to complete all records before the end of their shifts.
Infection Control Deficiencies in Glove and Gown Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of healthcare personnel not adhering to proper glove removal and hand hygiene protocols. On one occasion, a Certified Nurse Assistant (CNA) was observed exiting a resident's room without removing gloves or performing hand hygiene, and then entering another resident's room while still wearing the same gloves. This action was repeated by another CNA, who also failed to perform hand hygiene after exiting a resident's room and continued to provide care without changing gloves. Interviews with the Assistant Director of Nursing (ADON), Nurse #1, and the Director of Nursing (DON) confirmed that staff are required to remove gloves and perform hand hygiene before leaving a resident's room, and should not provide care to more than one resident with the same gloves. Additionally, the facility did not ensure that healthcare personnel donned precaution gowns when required by Enhanced Barrier Precautions (EBP). A CNA was observed emptying a urinary catheter drainage bag for a resident on EBP without wearing a precaution gown, despite a posted sign indicating the necessity of gown and glove use for such high-contact activities. Interviews with the CNA, Nurse #1, and the DON confirmed the requirement for wearing a precaution gown in addition to gloves during these activities. The Administrator acknowledged the absence of a specific facility policy on EBP, stating that the facility follows CDC guidance.
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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 Melrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Melrose Healthcare | 0.6 mi | ★★★★★ | 0 | 0 |
| Greenwood Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Stoneham | 1.5 mi | ★★★★★ | 15 | 0 |
| Regalcare At Glen Ridge | 2.3 mi | ★★★★★ | 35 | 0 |
| Dexter House Healthcare | 2.7 mi | ★★★★★ | 17 | 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 July 2026) and official state health department websites.