Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Elmwood Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with advanced dementia, nonverbal status, contractures, and total dependence for ADLs had a fall risk care plan requiring positioning in the center of the bed during repositioning and use of a mechanical lift with two staff for all transfers. While a NA was providing morning care and rolling the resident in bed to place a Hoyer pad, the resident rolled off the bed, causing both to fall and resulting in a head hematoma and subsequent subdural hematoma. Staff reported relying on assignment sheets, which listed the resident as Hoyer and total care but did not specify the need for two-person assistance with all care, and multiple staff, including an RN, were unaware of the updated care plan requirement for two-person assistance.
A resident with encephalopathy, who was rarely/never understood, was started on Zyprexa 5 mg daily for agitation after exhibiting behaviors such as pulling out a catheter and wound vac and refusing care. Facility policy required resident or representative consent for psychotropic medications, including explanation of risks, benefits, side effects, and black box warnings, and documentation of notification to the representative when a new medication signaled a change in condition. Review of the clinical record and MARs showed the resident received Zyprexa daily over multiple months, but there was no evidence that the resident’s representative was informed of the medication, its risks, benefits, or alternatives, and the DON could not provide documentation that the order had been reviewed with the representative before administration.
A resident with encephalopathy and a history of cardiac arrest had physician orders for a neurology consult related to recent shock and for psychiatric/psychological services, including a follow-up visit. Record review showed no evidence that the neurology consult was ever scheduled or completed, and no documentation that the psychiatric follow-up occurred within the ordered timeframe. In interviews, the physician reported he expected the facility to arrange these services, and the DON could not provide evidence that either the neurology consultation or the psychiatric follow-up had been carried out.
The facility failed to provide mandatory effective communication training for 7 direct care staff members caring for a resident who speaks Cantonese and could not communicate in English. The resident’s MDS listed Chinese as the preferred language, the care plan noted the resident does not speak the facility’s dominant language, and employee education records did not show completed communication training for an LPN, CMT, RN, NAs, and a dietary aide. The DON said she would expect communication education for staff, and the Administrator acknowledged effective communication was not included as mandatory training for staff.
A resident with cerebral palsy and lower-extremity contractures had a physician order to offload the right heel and ankle in bed using an ankle offloading device. Surveyors observed the right heel resting directly on the mattress while the device was placed on the left ankle instead, and the record did not show the resident could not tolerate the ordered device. An RN, CNA, and the DON all acknowledged the order and the incorrect placement of the offloading device.
A resident with Alzheimer’s disease who preferred Chinese and spoke a specific Cantonese dialect was not provided effective communication support consistent with the care plan. Staff were unaware of the resident’s language needs and of interpreter services, and surveyors observed the resident without translation cards or a Cantonese dictionary. The DON stated the facility did not have interpreter services available and could not show evidence of person-centered care honoring the resident’s preferences, choices, values, and beliefs.
Failure to maintain required staff training records. Record review showed that an LPN, CMT, RN, and two NAs lacked evidence of required annual education tied to their roles, including Trauma Informed Care, QAPI, Infection Control, Abuse, and dementia behavioral health management. The Administrator could not provide documentation of the missing trainings during surveyor interview, despite the facility assessment stating that yearly and as-needed education was to be provided through in-person in-services.
A resident with prostate cancer had a urology recommendation for a PSA test, but the facility did not show that the lab was completed or that the MD was contacted for an order. An RN said the facility’s process is to contact the PCP when a specialist recommendation is received, and the DON said the recommendation should have been reviewed by the nurse and turned into an MD order.
Medication Administration Error Rate Exceeded Allowed Threshold: Surveyors observed 2 medication administration errors during 28 opportunities, resulting in a 7.14% error rate. One CMT gave a resident only half of the ordered MiraLAX dose, and another CMT mixed a resident’s MiraLAX in less fluid than ordered. The DON stated physician orders should be followed.
Inadequate PPE use when handling soiled laundry. A laundry aide was observed handling soiled personal clothing and linens while wearing only gloves and no gown or apron. The aide stated she usually only wears gloves and uses a gown only for precautions or red-bag linen. Another laundry aide said she had not been told a gown or apron was required, and the IP stated staff only wear PPE for soiled laundry from residents on precautions rather than for all soiled laundry.
The facility did not ensure nursing staff had the necessary competencies for oxygen therapy, particularly for acute respiratory failure with hypoxia. Despite the resident population including individuals with such conditions, there was no evidence of related competencies for a newly hired RN. The DON confirmed the absence of specific education or competencies for administering oxygen.
A resident with dementia and COPD experienced acute respiratory failure with hypoxia. Despite being placed on oxygen, EMS found the resident's oxygen turned off and saturation at 84%. Staff interviews revealed issues with the oxygen concentrator and a lack of reevaluation by the RN. The DON expected proper assessment post-oxygen application.
Failure to Follow Fall Prevention Care Plan and Staffing Requirements During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide care in accordance with a resident’s fall prevention care plan, resulting in a fall with injury requiring hospitalization. The resident, admitted with Alzheimer’s disease and advanced dementia, was nonverbal, contracted, on a blood thinner twice daily, and required total assistance for all ADLs, including transfers and rolling in bed, with the helper doing all of the effort. The resident had an active fall risk care plan initiated in 2022 due to decline in condition, poor safety awareness, and lack of trunk control. This care plan was revised to direct staff to position the resident in the center of the bed during repositioning to prevent sliding out of bed and to require use of a mechanical lift with two staff for all transfers. On the date of the incident, a NA was providing morning care and applying a Hoyer pad by rolling the resident in bed. While attempting to roll the resident toward herself, the resident rolled off the bed, causing both the NA and the resident to fall to the floor, and the resident struck the right side of the head, resulting in a right temple hematoma and subsequent diagnoses of right frontal hematoma and subdural hematoma at the hospital. Surveyor review of records and interviews showed that staff, including an RN and another NA, relied on assignment sheets to determine required levels of assistance and were unaware that the resident’s care plan required two-person assistance with all care. The assignment sheet listed the resident as Hoyer, total care, and 1:1 feed, but did not indicate the need for two-person assistance with all care, and the DON stated she was unaware that the assignment sheet did not accurately reflect this requirement.
Failure to Obtain Representative Consent Prior to Initiation of Antipsychotic Medication
Penalty
Summary
The facility failed to obtain and document informed consent from a resident’s appointed representative prior to initiating an antipsychotic medication, Zyprexa, as required by facility policy. The facility’s policy on Medication Administration Safety, Psychotropic Medications and New Medication Orders, dated 4/28/2025, states that any psychotropic medication requires resident or representative consent, including awareness of the medication ordered, its side effects, black box warnings when applicable, and the risks and benefits, and that consent is necessary prior to administration. The policy also requires that when a new medication is ordered, this is considered a change in condition and the representative must be notified, with evidence of this notification documented in the progress notes or other parts of the medical record. Record review showed that the resident was readmitted in October 2025 with encephalopathy and was rarely/never understood per a Minimum Data Set assessment, indicating that a Brief Interview for Mental Status was not conducted. A physician progress note dated 10/27/2025 documented that the resident had been pulling out a catheter and wound vac and refusing care, and an order for Zyprexa 5 mg for agitation was written. Medication Administration Records for October, November, and December 2025, and January 2026 showed that the resident received Zyprexa 5 mg daily from 10/27/2025 through 1/13/2026. Further review of the clinical record failed to reveal any evidence that the resident’s representative was informed of the Zyprexa order or of the risks, benefits, and alternatives to the medication. During an interview on 1/14/2026, the Director of Nursing Services was unable to provide evidence that the order for Zyprexa was reviewed with the resident’s representative prior to initiation of the medication.
Failure to Follow Physician Orders for Neurology and Psychiatric Consults
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for specialty consultations. A resident was readmitted in October 2025 with diagnoses including encephalopathy and cardiac arrest. The clinical record showed a physician’s order dated 10/6/2025 for a neurology consult related to recent shock. Record review did not contain any evidence that this neurology consult was ever scheduled or completed after the order was written. The record also showed a physician’s order dated 10/16/2025 for a psychiatric and psychological health evaluation. A psychiatric evaluation and consultation form dated 10/28/2025 documented an assessment plan that included a follow-up in 30–45 days. Further record review did not show that the resident was seen for the ordered psychiatric follow-up. In interviews, the physician stated he expected the facility to schedule the neurology consultation and ensure psychiatric follow-up occurred, and the Director of Nursing Services was unable to provide evidence that either the neurology consultation had been scheduled or completed, or that the psychiatric follow-up visit had occurred.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory effective communication training for 7 of 7 direct care staff members, including an LPN, a CMT, multiple NAs, an RN, and a dietary aide, regarding a resident who only speaks Cantonese and was unable to communicate in English during surveyor interview. Review of the resident’s Quarterly MDS assessment showed a preferred language of Chinese, and the care plan stated that the resident does not speak the dominant language of the facility and speaks Cantonese. Review of employee education records did not show evidence that effective communication training had been completed for Staff K, L, M, N, O, P, and Q in order to communicate successfully with the resident. During interviews, the DON stated she would expect the facility to provide communication education to staff members, and the Administrator acknowledged that the facility does not include effective communications as mandatory training for any facility staff members, as required.
Failure to Follow Heel Offloading Order
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to the use of a heel offloading device. The resident was readmitted in January 2025 with diagnoses including cerebral palsy and contractures of the right and left lower legs. A physician’s order dated 8/26/2024 directed staff to offload the resident’s right heel and ankle when in bed, as tolerated, using an ankle offloading device. Surveyor observations on 9/3/2025 and 9/5/2025 found the resident’s right heel lying directly on the mattress rather than being offloaded, and the device was observed on the left ankle instead of the right. Record review did not show evidence that the resident could not tolerate the ordered offloading device. During interviews, an RN acknowledged the right heel was on the mattress and stated the device had been placed on the left ankle; she also stated the resident’s heels did not need to be offloaded because an air mattress was being used. A CNA likewise acknowledged the device had not been placed on the resident’s right ankle. The DON stated it was her expectation that the right heel and ankle offloading device be in place as ordered.
Failure to Support Communication and Person-Centered Care for a Cantonese-Speaking Resident
Penalty
Summary
The facility failed to ensure that care and services were person-centered and that the resident’s preferences, choices, values, and beliefs were honored for a resident admitted in February 2005 with diagnoses including Alzheimer’s disease. The resident was unable to communicate in English and, per the MDS, preferred Chinese. The care plan identified that the resident spoke Cantonese and included interventions to encourage use of flash cards, visual cueing, interpreter services, and a foreign language dictionary to support communication, but the flash cards labeled Communication Cards English and/or Chinese traditional did not contain evidence of Cantonese-specific content. Survey observations showed the resident lying in bed on multiple occasions without translation cards or a Cantonese language dictionary present. Staff interviews revealed that the RN, Activity Director, Activity Aide, Nursing Assistant, Medication Technician, and DON were unaware of what type of Chinese language the resident spoke and were unaware of interpreter services to communicate with the resident. The RN stated she called the resident’s family member to help translate, and the family member confirmed the resident only speaks a specific dialect of Cantonese. The DON stated the facility did not have interpreter services available for residents and could not provide evidence of person-centered care that honored and supported this resident’s preferences, choices, values, and beliefs.
Failure to Maintain Required Staff Training Records
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for newly hired and existing staff members consistent with their expected roles. Record review and staff interview showed that required annual education was not documented for multiple employees, including training related to abuse, infection control, dementia behavioral health management, trauma informed care, and QAPI as identified in the facility assessment. The facility assessment, last updated 1/5/2025, stated that education and training competencies related to resident-specific services were to be provided yearly and as needed, using in-person in-services for annual education and new hire training. Record review showed that an LPN hired on 3/23/2018 had no evidence of annual Trauma Informed Care education. A CMT hired on 10/12/2023 had no evidence of annual Trauma Informed Care or QAPI education. A NA hired on 4/12/2024 and an RN hired on 6/25/2024 also had no evidence of annual Trauma Informed Care or QAPI education. Another NA hired on 8/2/2024 had no evidence of annual education in Infection Control, Abuse, Dementia behavioral health management, Trauma Informed Care, or QAPI. During interview on 9/5/2025, the Administrator could not provide evidence of the required trainings for these five staff members.
Failure to Follow Urology Recommendation for PSA Testing
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for a resident with a history of malignant neoplasm of the prostate and a urology follow-up recommendation. Record review showed that an After Visit Summary from the urologist recommended obtaining a PSA test to monitor for prostate cancer, but review of the resident’s laboratory results did not show that the PSA was completed after the recommendation or that the facility physician was contacted to obtain an order for the lab work. During interview, an RN stated it is the facility’s procedure to contact the primary care physician when a specialist treatment recommendation is received, but she could not provide evidence of the laboratory results. The DON stated the recommendation should have been reviewed by the facility nurse upon receipt and a physician’s order should have been obtained, and that the PSA recommendation was later reviewed and approved with the provider after it was brought to the facility’s attention by the surveyor.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure residents’ medication regimens were free from a medication error rate of 5% or greater. During observation of 28 medication administration opportunities, surveyors identified 2 errors, resulting in an error rate of 7.14% and affecting Resident ID #2 and Resident ID #64. The facility policy titled Medication Administration Safety Program states that residents shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines. Resident ID #64 had a physician’s order dated 5/13/2025 for two doses of polyethylene glycol 3355 powder (MiraLAX) 17 grams for a total dose of 34 grams once daily. During observation of the medication administration task on 9/4/2025, a CMT administered 17 grams instead of the ordered 34 grams. In a later interview, the CMT acknowledged giving only 17 grams. Resident ID #2 had a physician’s order dated 8/20/2025 for MiraLAX 17 grams with instructions to mix it in 4 to 6 ounces of fluid. During observation of medication administration on 9/4/2025, a CMT mixed the MiraLAX in approximately 2 ounces of fluid instead of the ordered amount. The CMT later acknowledged the amount of fluid used and stated she was unaware the order specified a particular amount. The DON stated she would expect physician orders to be followed.
Inadequate PPE Use When Handling Soiled Laundry
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to staff wearing appropriate PPE while handling soiled linen. A review of the facility policy, Infection Control Guidelines for Housekeeping/Laundry, stated that all laundry is to be handled as potentially infectious and that laundry workers are to wear appropriate PPE, including at minimum a gown or apron, with face mask protection available and used when there is a possibility of splashing body fluids into the mouth, nose, or eyes. During observation, Laundry Aide Staff I was seen handling soiled personal clothing and linens in the soiled linen room while wearing only procedure gloves and no gown or apron. During interview, Staff I stated she usually only wears gloves when handling soiled linens and only wears a gown if told a resident is on precautions or if the linen is in a red bag. Another Laundry Aide, Staff J, stated she had not been made aware that a gown or apron should be worn when handling soiled linens. The Infection Preventionist stated that staff only wear PPE for handling soiled laundry for residents on precautions and not for all residents' soiled laundry.
Lack of Competency in Oxygen Therapy for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide appropriate care for residents, specifically in relation to oxygen therapy for acute respiratory failure with hypoxia. The facility's assessment indicated that the resident population included individuals with chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. Despite this, there was no evidence of competencies or skill sets related to oxygen therapy for Registered Nurse, Staff A, who was hired on 6/25/2024. During an interview, the Director of Nursing Services confirmed that the facility did not provide education or competencies specifically related to administering oxygen for any nursing staff.
Failure in Oxygen Administration During Acute Medical Event
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice during an acute medical event. The resident, who had a history of dementia and chronic obstructive pulmonary disease, was experiencing acute respiratory failure with hypoxia. A Nurse Practitioner assessed the resident and initiated oxygen therapy for oxygen saturation levels below 91%, with a goal of 90 to 97%. However, a late entry nursing progress note revealed that the resident's oxygen saturation was 85% on room air, and the resident was placed on 2 liters of oxygen via nasal cannula. Despite this, when EMS arrived, the resident's oxygen was turned off, and the oxygen saturation was 84% on room air. Interviews with staff revealed that a Nursing Assistant noticed the resident was sick and on oxygen, but the concentrator was beeping. The RN was informed and attempted to reset the concentrator, but it continued to malfunction. The RN acknowledged not reevaluating the resident after placing them on oxygen. The Director of Nursing Services stated that she would expect the nurse to assess the resident's oxygen saturation after applying oxygen. The deficiency was identified as a failure to maintain professional standards of care in oxygen administration during an acute medical event.
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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 Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Providence Dodge Rehab Center, Llc | 0.5 mi | ★★★★★ | 4 | 0 |
| Steere House Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Tockwotton On The Waterfront | 1.9 mi | ★★★★★ | 5 | 0 |
| Elmhurst Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 10 | 1 |
| Scandinavian Home Inc | 2.5 mi | ★★★★★ | 0 | 0 |
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