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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elms Retirement Village Inc during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions was given twice the prescribed dose of Dilaudid by an agency LPN on two occasions. The medication error was discovered during a narcotic count, but there was no documentation or evidence that the resident, her legal representative, or her physician were notified of the error, as required by facility policy.
A resident with complex medical needs received twice the prescribed dose of Dilaudid on two occasions when an agency LPN administered extra tablets. The error was discovered during a narcotic count, but there was no documentation of the incident in the resident's progress notes or confirmation that the physician was notified, contrary to facility policy.
The facility failed to notify physicians about unavailable medications for two residents, leading to missed doses of critical medications. One resident did not receive several doses of prescribed medications, including antibiotics and pain relief, while another missed a dose of torsemide for edema. The DON stated it was not protocol to notify physicians of missing doses for new residents, contrary to facility policy.
A resident with complex medical needs, including osteomyelitis and hypotension, did not receive prescribed medications and was inadequately monitored during their stay. The MAR showed multiple missed doses, and only one set of vital signs was documented. Interviews revealed that staff did not conduct necessary assessments due to the absence of medications, leading to a deficiency finding.
Two residents in a LTC facility experienced significant delays in receiving prescribed medications due to delivery issues. One resident, admitted with multiple diagnoses, missed several doses of critical medications, leading to a call to emergency services by a concerned family member. Another resident with cardiac issues did not receive a newly prescribed medication due to a missed delivery cut-off. The facility's pharmacy contract promised daily deliveries, but the schedule led to non-compliance with pharmaceutical service requirements.
Two residents experienced significant medication errors due to delayed pharmacy deliveries. One resident missed doses of Cefazolin IV and midodrine, leading to a hospital admission for a wound infection. Another resident did not receive torsemide for edema as it was unavailable, with the medication delivered late and administered the next day. The facility's failure to ensure timely medication administration resulted in these errors.
Failure to Notify Resident, Physician, and Representative of Medication Error
Penalty
Summary
The facility failed to notify a resident, her legal representative, and her physician of a medication error involving the administration of Dilaudid. The resident, who had diagnoses including quadriplegia, stage four wounds, osteomyelitis, severe malnutrition, anxiety disorder, depression, and cachexia, was cognitively intact and had a Power of Attorney. According to the medical record and medication administration records, an agency LPN administered twice the prescribed dosage of Dilaudid at two separate times. The error was discovered during a narcotic count at shift change, and it was documented that the nurse had given an extra total of 8 mg of Dilaudid. Despite the facility's policy requiring immediate notification and documentation to the resident, physician, and family in the event of a medication error, there was no evidence in the medical record or progress notes that any of these parties were notified. The DON confirmed that although the physician was verbally informed, this was not documented, and there was no record of notification to the resident or her legal representative. The lack of documentation and notification constituted the deficiency.
Failure to Prevent Significant Medication Error and Incomplete Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, stage four wounds, osteomyelitis, severe malnutrition, anxiety, depression, and cachexia, was admitted to the facility and had intact cognition. The resident had a physician's order for Dilaudid 4 mg to be administered four times daily for chronic pain. On two occasions, an agency LPN administered twice the prescribed dosage of Dilaudid, giving an extra 4 mg at both the midnight and morning doses, resulting in a total of 8 mg extra being given. This medication error was discovered during a narcotic count at shift change. Review of the facility's documentation revealed that the medication error was not recorded in the resident's progress notes for the days following the incident. Additionally, although the DON stated that the physician was notified of the error, there was no documentation to confirm this communication. The facility's policy required all medication errors to be appropriately documented and tracked, but this was not followed in this instance.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify the physician of unavailable medications for two residents, leading to a deficiency in care. Resident #51, who was admitted with conditions such as osteomyelitis and multiple sclerosis, did not receive several doses of prescribed medications, including antibiotics and pain relief, due to unavailability. The Medication Administration Record (MAR) showed missing doses, and there was no evidence that the physician was informed of these omissions. The Director of Nursing (DON) stated that it was not the facility's protocol to notify physicians of missing doses for new residents, and the Nurse Practitioner was unaware of the missed medications, expressing concern over the lack of notification. Similarly, Resident #29, with diagnoses including diverticulosis and atrial fibrillation, did not receive a scheduled dose of torsemide for edema due to its unavailability. The medication was not found in the medication cart or the pyxis system, and although the pharmacy was contacted, there was no documentation that the physician was notified of the delay. The DON indicated that due to an order stating new medications would be initiated upon pharmacy delivery, the physician did not need to be notified. However, this was contrary to the facility's policy, which required notifying the physician of any significant changes or incidents involving the resident.
Failure to Monitor Resident Status and Administer Medications
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's status, which affected one resident out of three reviewed for quality of care. The resident, who was admitted with diagnoses including osteomyelitis, multiple sclerosis, and hypotension, did not receive any medications from the pharmacy prior to discharge. The Medication Administration Record (MAR) indicated multiple missed doses of medications, including antibiotics, pain medication, and blood pressure medication. Despite the resident's complex medical needs, there was only one set of vital signs documented, and no additional assessments were completed on the day following admission. Interviews with facility staff revealed a lack of monitoring and assessment for the resident. A Registered Nurse stated that skilled assessments are completed on the night shift and admitted to not monitoring the resident due to the absence of medications. The Director of Nursing also indicated that there was no reason to monitor the resident's blood pressure or assess for signs of infection without the medications. The Nurse Practitioner expressed concern upon learning that the resident did not receive any medications and was not being monitored or assessed. This deficiency was investigated under a specific complaint number.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure medications were available for administration, affecting two residents. Resident #51 was admitted with multiple diagnoses, including osteomyelitis and multiple sclerosis, and had a comprehensive list of medications prescribed upon admission. However, the Medication Administration Record (MAR) showed that several doses of these medications were missed, including critical ones like Cefazolin and oxycodone. Interviews with nursing staff revealed that the medications were not delivered in a timely manner, and the resident's husband was so concerned about the lack of care that he called emergency medical services. Resident #29, who had diagnoses including diverticulosis and atrial fibrillation, also experienced a delay in receiving medication. A physician's order for torsemide was placed, but during a medication administration observation, it was found that the medication was not available in the cart or the pyxis system. The pharmacy was contacted, and it was confirmed that the medication missed the delivery cut-off time and was not delivered until the following day. The facility's pharmacy contract indicated that deliveries were to be made daily, with an additional delivery in emergencies. However, the pharmacy's delivery schedule and the facility's admission times led to significant delays in medication administration for both residents. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with pharmaceutical service requirements.
Medication Errors Due to Delayed Pharmacy Deliveries
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #51, who had diagnoses including osteomyelitis and multiple sclerosis, was admitted to the facility and had orders for Cefazolin IV and midodrine. However, on 10/09/24, two doses of each medication were not administered because they were not available. The resident's husband reported that no antibiotics were received from the pharmacy during their 20-hour stay, leading to the resident's admission to the hospital for a wound infection and osteomyelitis. The Director of Nursing (DON) acknowledged the delay in medication delivery due to missing the pharmacy cut-off time. Resident #29, with diagnoses including diverticulosis and atrial fibrillation, had a new order for torsemide due to increased weight and edema. On 11/06/24, the medication was not administered as it was not available in the medication cart or the pyxis system. The Registered Nurse (RN) noted the pharmacy was contacted, and the medication was to be delivered in the next drop-off. The pharmacist confirmed the order missed the cut-off time and was delivered the following evening. The DON stated the medication was administered the next morning, as it was not appropriate to administer it upon late delivery. These incidents highlight the facility's failure to provide timely medication administration due to pharmacy delivery issues, resulting in significant medication errors for the residents involved. The deficiency was investigated under Complaint Number OH00158867.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keystone Pointe Health And Rehabilitation | 7.2 mi | ★★★★★ | 0 | 0 |
| Welcome Nursing Home | 7.8 mi | ★★★★★ | 29 | 0 |
| Kendal At Oberlin | 9.3 mi | ★★★★★ | 0 | 0 |
| Laurels Of New London The | 11.4 mi | ★★★★★ | 0 | 0 |
| Wesleyan Village | 14.4 mi | ★★★★★ | 0 | 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 June 2026) and official state health department websites.