Elmwood Manor Nursing Home

Penalty

Inspection fine: $17,215

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident did not fall from a mechanical lift during a transfer, resulting in a fall and injury. The facility had a Safe Lifting & Mechanical Lift Policy dated 01/01/25 that required use of proper sling and equipment, two trained staff for transfers, and adherence to manufacturer instructions. The resident’s care plan for activities of daily living, dated 10/30/25, specified the need for a mechanical lift for transfers, and a quarterly assessment dated 12/31/25 documented that the resident was cognitively intact with a BIMS score of 15 and was dependent on staff for mobility. On 11/13/25, a late entry nursing progress note recorded that an LPN found the resident on the floor under the mechanical lift, with the resident complaining of pain all over, and the resident was sent to the emergency room for evaluation. A hospital imaging report from the same day showed a nondisplaced fracture deformity of the distal femur in the resident’s right leg. A facility incident report dated 11/14/25 documented that the resident fell from a mechanical lift while being transferred by two CNAs. The resident’s fall care plan, dated 11/17/25, stated that the resident had been up in a mechanical lift when a sling loop came off the lift, causing the resident to fall to the floor toward the right lower corner of the sling, and that the resident was sent to the hospital for evaluation and treatment. CNAs interviewed later stated they were responsible for inspecting the lift before use, ensuring the resident was correctly positioned in the sling, and confirming that hooks or straps were properly secured. The administrator identified that 19 residents in the facility were dependent on mechanical lifts for transfers and there was no documentation that quality assurance was involved in the process.

Penalty

Inspection fine: $16,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an incident where one resident inappropriately raised another resident's shirt and grabbed their breast in a public area. Prior to this event, there were documented behavioral issues involving the same resident, including making other residents uncomfortable, using vulgar language, and inappropriate physical contact such as kissing another resident. Despite these documented behaviors, the care plan for the resident exhibiting inappropriate sexual behaviors did not include sufficient interventions beyond medication management, and there was a lack of comprehensive measures to prevent further incidents. Multiple residents with cognitive impairments and communication deficits were involved or affected by the inappropriate behaviors. One resident had diagnoses including bipolar disorder, Alzheimer's, and moderate cognitive impairment, while the resident who committed the abuse had severe cognitive impairment and a history of inappropriate sexual behaviors. Other residents reported feeling violated or uncomfortable due to the actions of the same resident, and there were staff observations of ongoing inappropriate comments and behaviors directed at both residents and staff. The facility did not conduct timely or thorough investigations into reported incidents of sexual abuse. For example, after a reported incident of inappropriate touching, the administrator acknowledged that no investigation had been conducted. Additionally, staff interviews revealed that safe surveys regarding abuse were not completed, and there was a lack of documentation and follow-up on previous incidents. These failures contributed to an environment where residents were not adequately protected from abuse, neglect, and exploitation.

Removal Plan

• General Manager completed the Process for Completion of a State Reportable.
• Administrator completed training on Abuse and Neglect and on Conducting an Abuse Investigation.
• In-service provided to Administrator and Corporate Nurse on Abuse investigation, Reporting, Completion, Conducting and the updated abuse policy.
• All staff educated on abuse, neglect, and exploitation by Administrator.
• Resident #2 educated on abuse and resident's rights.
• All staff educated on the reporting structure and provided contact information for the administrator of record.
• Resident #2 placed on one-on-one monitoring with direct care staff or designee when out of resident's room.
• Resident #2 medications to be reviewed by Psych NP and MD to assist with potential reduction and behaviors due to side effects if applicable.
• All findings and audits to be reviewed by Director of Nursing, Administrator and/or designees.
• Review of residents to list any residents at risk for inappropriate unwanted behavior, list to be done by Director of Nursing.
• All at risk residents will not be placed near Resident #2.
• All at risk residents will be care planned with interventions of maintaining placement when out of room away from Resident #2.
• All at risk residents who are at risk for unwanted behavior will be added to the shift monitor report so that the charge nurse and staff are aware to maintain distance from Resident #2.
• Facility will work with active family member to restructure visit times to be scheduled during high aggressive times once identified.
• Resident #1 will be monitored by the charge nurse for any psychosocial alterations.
• All staff and current residents interviewed to rule out abuse, neglect or exploitation using a safe survey.
• Abuse, neglect and exploitation policy updated to include specific verbiage on inappropriate sexual behaviors in the screening, training, prevention, and identification components.
• A QA was created and implemented pertaining to the inappropriate behaviors of Resident #2 with interventions.
• A monitoring form for interventions for Resident #2 was created and implemented.
• Education provided to activities/social services staff to do 1:1 activities with Resident #2 after lunch.
• Care plan for Resident #2 updated to include the interventions put into place.
• Care plan for Resident #1 updated to include the psychosocial monitoring and an order placed in the EMAR to be monitored by nurses.
• Resident #2's medication reviewed and Prevera dosage increased.
• Non-verbal/incapacitated residents interviewed using observation for facial expressions, gestures, and emotional cues/reactions.
• All staff instructed via electronic in-service to keep Resident #2 away from all residents identified as vulnerable or at risk of inappropriate behavior.
• When Resident #2 is out of room, staff instructed to move Resident #2 away from all identified at-risk residents in public areas, assigned to all staff and documented on daily monitoring form by charge nurse.
• Exception documentation if behavior occurs in the nursing notes and behavior record, to be completed by charge nurses.
• In-service documentation showed clinical staff attended in-person and via telephone training by the administrator over the facility's abuse policy.
• Resident #2's care plans updated to show 1:1 intervention and medication dosage increased to reduce behaviors.
• Resident #2 observed to ensure 1:1 intervention by clinical staff.
• Residents #1, #4, and #5 observed to ensure they maintained a safe distance from Resident #2.
• A list for residents with unwanted behaviors posted at the nurse's station.
• QA documentation showed the facility had a meeting where they addressed the abuse incident.
• General manager documentation for in-service completion for state reportable training reviewed.

Penalty

Inspection fine: $16,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide required supervision and assistance during mealtime for a resident with a known history of choking incidents and an established care plan requiring assistance with dining. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and was cognitively intact. The care plan specified a mechanical soft diet with chopped meats and required staff assistance with meal setup and feeding due to previous episodes of choking and difficulty with certain food textures. Despite these documented needs, the resident was left unsupervised while eating in their room. Multiple nursing notes and care plan entries indicated the resident had previously choked on meats, had been observed coughing frequently during meals, and had expressed concerns about getting 'strangled' on tough meat. On the day of the incident, the resident was found alone in their room, in distress and choking, with no staff present to provide immediate assistance. Staff were occupied distributing meal trays in the hallway at the time. When the resident activated the call light, a CNA responded and found the resident choking, attempting to perform the Heimlich maneuver with assistance from another CNA and an LPN. Despite these efforts, the resident was pronounced dead by EMS. Interviews with staff confirmed that the resident was not being monitored during the meal, contrary to the care plan and facility policy, which required supervision and assistance for residents at risk of choking.

Removal Plan

• Review all residents' nutritional care plans and diets for choking risk, non-compliance with diets, therapeutic diets, and assisted feeding needs.
• Identify residents at risk of choking or non-compliance with diet orders/recommendations or who require assistance with feeding.
• Update nutritional care plans for all residents identified as choking risk by clinical staff.
• Create a quick reference chart (diet reference list) for all clinical and dietary staff, including meal location preferences, diet (including consistency), portion, and protein supplements; place the chart at the nurse's station, in the nurse shift book, in the kitchen on the bulletin board, and in the CNA shift report book.
• Create a policy addendum on choking or dietary non-compliance and add it to the assistance with meals policy, including key personnel to contact regarding choking or dietary non-compliance events and assessment of the resident to determine the need for treatment such as the Heimlich maneuver.
• Create and implement a CPR policy and procedure specifying when to initiate CPR, training and competency requirements, require all clinical staff to maintain valid CPR/BLS certification, require newly hired staff to obtain CPR certification, require CPR recertification, allow a grace period for renewal, and maintain proof of certification in personnel files.
• Provide in-service education for all clinical staff on supervision during meals, including procedures for meal supervision and 1:1 staff presence for residents requiring feeding assistance or at risk of choking.
• Provide in-service education on how to locate and follow care plans in the electronic health record, and instruct staff to notify the charge nurse if they cannot access needed information.
• Provide in-service education on procedures related to a choking event, including identification of choking risk residents, reporting choking events, and reporting dietary compliance issues.
• Train all clinical staff on CPR and Heimlich maneuver.
• Conduct a Quality Assurance Performance Improvement Project (PIP) to address assisting and monitoring residents named as choking risk and 1:1 supervision of residents during mealtimes until meal is completed.
• Implement quality assurance monitoring: monitor residents at risk for choking by DON/designee.

Penalty

Inspection fine: $16,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the treatment cart containing drugs and biologicals, including insulin pens and vials, was locked and supervised when not in use. On multiple occasions, the treatment cart was observed unlocked and unsupervised near the nurse's station, with licensed nursing staff away from the cart and out of sight. Facility policy required that medication carts be securely locked at all times when out of the nurse's view, and staff interviews confirmed awareness of this responsibility. The treatment cart was reported to contain insulin and PEG tube supplies, and the facility had a total of two medication carts and one treatment cart for 39 residents.

Penalty

Inspection fine: $16,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of abuse involving one resident out of eight sampled for abuse. According to facility policy, all reports of resident abuse, neglect, and injuries of unknown source are to be promptly and thoroughly investigated, including obtaining written and signed witness statements, interviewing all relevant staff, witnesses, and reviewing events leading up to the incident. However, following an incident where one resident was observed inappropriately touching another resident, the investigation was incomplete. The general manager acknowledged that a full investigation, including obtaining witness statements, was not conducted, and the administrator confirmed that no witness statements were available for the incident.

Penalty

Inspection fine: $16,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to track and monitor a choking incident involving one resident, as required by its policy on safety and supervision. According to the nursing note, staff responded to a resident who was choking, and paramedics later pronounced the resident deceased. Despite this serious event, there was no documentation in the quality assurance notes regarding monitoring or tracking of the incident. The corporate nurse confirmed that the incident was neither reviewed nor documented by the quality assurance group, contrary to facility policy that mandates QA review of safety and incident reports.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a physician responded to a pharmacist's medication regimen review (MRR) and did not document the physician's rationale for declining a gradual dose reduction (GDR) for two residents. Resident #6, who had diagnoses including dementia, schizophrenia, unspecified psychosis, and insomnia, was prescribed multiple medications such as ramelteon, Trintellix, desvenlafaxine, Vraylar, and olanzapine. An MRR report indicated the need for a GDR for these medications, but there was no documented response from the physician. The Director of Nursing (DON) was unaware of the MRR process, and the MDS coordinator confirmed the lack of physician response. Resident #26, diagnosed with dementia, depression, and insomnia, was prescribed medications including trazadone, Lexapro, Remeron, lamotrigine, and Invega. An MRR report suggested a GDR for these medications, but the physician disagreed with the request without providing a documented rationale. The MDS coordinator and the corporate nurse consultant acknowledged the absence of a documented rationale for the physician's decision. These deficiencies highlight the facility's failure to adhere to its policy requiring physician responses and rationales for MRR recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident receiving psychotropic medications had an appropriate diagnosis for the use of antipsychotic medication. The resident, who was admitted with diagnoses including dementia and depression, was prescribed cariprazine and Invega, both antipsychotic medications, for unspecified dementia without psychotic or behavioral disturbances. An annual assessment indicated the resident was severely cognitively impaired, had no symptoms of depression or behaviors, yet continued to receive antipsychotic medication. Interviews with the MDS coordinator and the corporate nurse consultant confirmed that dementia was not an appropriate diagnosis for the use of antipsychotic medications, highlighting a deficiency in the facility's medication management practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store food in accordance with professional standards for food service safety, as observed during an initial kitchen tour. Raw hamburger patties were improperly stored on top of pre-cooked and sliced sandwich meat, and deli-sliced ham was placed on top of raw hamburger patties in a refrigerator. Additionally, two gallon pour top jugs containing brown and orange liquids were not dated or labeled. In the dry storage area, an undated and unlabeled blue bag, identified by staff as containing raisins, was found. Furthermore, zucchini in a refrigerator was covered with a grey and white fuzzy substance, indicating spoilage. The kitchen floor was also noted to have debris and food particles. A staff member acknowledged that raw meat should not be stored with cooked meat and that food items should be labeled and dated when prepared, stored, or opened.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is part of their maintenance program, to identify potential areas of entrapment. This deficiency was identified during an observation, record review, and interview process. A resident with diagnoses including fusion of the cervical spine, central cord syndrome, and muscle weakness, who was cognitively intact and required extensive assistance with bed mobility, was found to have bilateral half bed rails in the up position for repositioning purposes. Despite a physician's order and care plan allowing the use of bed rails for repositioning, the facility did not maintain records of regular inspections of these bed rails, as confirmed by the administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medication as ordered for a resident diagnosed with schizophrenia, auditory hallucinations, and bipolar disorder. Upon admission, the resident was prescribed clozapine, an antipsychotic medication, with specific instructions to administer two tablets at bedtime and one tablet twice daily. However, discrepancies were found in the medication administration records (MAR) and pharmacy logs, indicating that the resident received more tablets than were documented as received by the facility. Specifically, the records showed that the resident received 323 tablets over three months, while only 237 tablets were documented as received. Interviews with staff revealed that one certified medication aide (CMA) admitted to administering one of the three daily doses, while another CMA, who was unavailable for interview, was responsible for the remaining doses. It was suggested that the second CMA may have used leftover medication from a discharged resident to compensate for the shortage. The administrator and corporate nurse consultant confirmed that the medication was not administered according to physician orders, and the issue was not previously reported to them by the staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update a care plan to include an order for oxygen for a resident diagnosed with COPD. A physician's order, dated August 15, 2024, specified that the resident was to receive oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation above 90%. On October 21, 2024, the resident was observed in bed with an oxygen concentrator delivering oxygen at two liters per minute via nasal cannula. However, the resident's care plan did not document the administration of oxygen. On October 24, 2024, the MDS coordinator confirmed that oxygen should have been included in the care plan but was not documented.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent before utilizing bed rails for a resident. The resident, who had diagnoses including fusion of the cervical spine, central cord syndrome, and muscle weakness, was cognitively intact and required extensive assistance with bed mobility. A physician order allowed the use of half rails for repositioning, and the care plan documented the resident's ability to use side rails for repositioning and rolling in bed. However, there was no documentation of informed consent for the use of bed rails in the resident's medical record. The corporate nurse consultant confirmed that informed consent was not obtained prior to the use of bedrails.