Inspection Report
Plan of Correction
Deficiencies: 1
Jan 6, 2026
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance related to the facility's regulatory deficiencies.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective January 6, 2026.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Nov 13, 2025
Visit Reason
The inspection was conducted as a result of complaint #2588287-C, investigating allegations related to resident safety and supervision.
Findings
The facility failed to ensure safe transferring techniques for Resident #4, who experienced multiple falls and required two staff for assistance. The care plan was not consistently followed, leading to a deficiency in accident prevention and supervision.
Complaint Details
Complaint #2588287-C was substantiated, resulting in a deficiency related to accident hazards and supervision.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff used safe transferring techniques for Resident #4, resulting in falls and inadequate supervision. | SS = D |
Report Facts
Resident census: 46
BIMS score: 12
Fall risk: 1
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pat Voelker | Administrator | Signed the report |
| Staff D | CNA | Provided statements about Resident #4's transfers and assistance |
| Staff C | CNA | Provided statements about Resident #4's transfer assistance |
| Director of Nursing | Director of Nursing | Acknowledged not working during Resident #4's fall and confirmed therapy recommendations |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 17, 2024
Visit Reason
An onsite revisit of the health survey ending November 14, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 3, 2024.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 9
Nov 14, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #124258-C and facility reported incident #123797-I.
Findings
The facility was found to have multiple deficiencies related to resident rights, comprehensive assessments, care planning, infection control, and safety measures. Specific issues included undignified treatment of a resident, incomplete comprehensive assessments, inadequate care plans for residents with infections and mobility issues, improper medication administration practices, and failure to follow proper sanitation and infection prevention protocols.
Complaint Details
Complaint #124258-C was not substantiated. Facility reported incident #123797-I was substantiated.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure all residents were treated with dignity and respect; staff were demanding, forceful, and demeaning to Resident #96. |
| Facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for Resident #35. |
| Facility failed to develop and implement comprehensive person-centered care plans for residents, including Resident #22 with multidrug-resistant organism (MDRO). |
| Facility failed to provide services to increase mobility or prevent loss in mobility for Resident #12. |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #37 who fell and sustained injuries. |
| Facility failed to provide respiratory care and services in accordance with professional standards for Resident #6 requiring a nebulizer. |
| Facility failed to follow proper hand hygiene and glove use during medication administration. |
| Facility failed to follow proper sanitation to prevent spread of illness; dishwasher temperatures were not consistently maintained at required levels. |
| Facility failed to establish and maintain an infection prevention and control program including proper use of Enhanced Barrier Precautions (EBP) for residents with MDROs. |
Report Facts
Facility census: 43
Residents reviewed: 14
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 1
Dishwasher temperature checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication administration deficiency for improper glove use. |
| Director of Nursing (DON) | Provided statements regarding staff training and infection control policies. | |
| Staff D | Involved in undignified treatment of Resident #96. | |
| Staff F | Registered Nurse (RN) | Witnessed and reported on incident involving Resident #96. |
| Staff H | Observed and reported on staff interactions with Resident #96. | |
| Staff E | Licensed Practical Nurse (LPN) | Reported on agitation of Resident #96 and staff interactions. |
| Staff G | MDS Coordinator | Provided information on MDS assessment completion. |
| Staff Q | Nursing Consultant | Provided expectations for care plans related to MRSA. |
| Staff C | Certified Nurse Aide (CNA) | Observed and reported on Resident #37 fall incident. |
| Staff B | Registered Nurse (RN) | Reported on Resident #37 fall and injury. |
| Staff J | Registered Nurse (RN) | Reported on nebulizer tubing maintenance. |
| Staff K | Health Unit Coordinator (HUC) | Reported on treatment administration record completion. |
| Staff L | Registered Nurse (RN) | Observed hand hygiene and care for Resident #9. |
| Staff M | Dietary Aide | Reported on dishwasher temperature and sanitation. |
| Staff N | Certified Dietary Manager | Reported on dishwasher maintenance and temperature issues. |
| Staff P | Dish Machine Maintenance Technician | Reported on dishwasher service and maintenance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 21, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies identified during the inspection.
Findings
Elm Crest Retirement Home is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Jul 21, 2024
Visit Reason
The inspection was conducted as a result of investigation of facility reported incidents #119835-I, #121288-I, and #121671-I, with one incident substantiated.
Findings
The facility failed to meet requirements related to comprehensive care plans and quality of care, including failure to review and revise care plans for residents with falls and cognitive impairments, and failure to implement fall prevention protocols. The facility reported a census of 44 residents and identified deficiencies in care plan timing, revision, and fall risk management.
Complaint Details
Facility reported incidents #119835-I and #121288-I were not substantiated. Incident #121671 was substantiated.
Severity Breakdown
Level 3: 1
Level 4: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and revise comprehensive care plans within 7 days after assessment for residents with major injuries and cognitive impairments. | Level 3 |
| Failure to provide needed services in accordance with professional standards, resulting in falls with major injury for 2 of 4 residents and failure to implement fall prevention protocols. | Level 4 |
Report Facts
Residents reviewed: 4
Census: 44
Fall incidents with major injury: 2
Care plan review timeframe: 7
Audit duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Provided observations on Resident #1's mobility and assistance needs |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 and provided statements on transfers |
| Staff H | Certified Medication Aide (CMA) | Stated Resident #3 required 1-2 staff assistance for transfers |
| Staff I | Registered Nurse (RN) | Stated Resident #3 completed transfers with assistance |
| Staff C | Registered Nurse, Director of Nursing | Provided statements on fall assessment and care plan documentation |
| Staff A | Licensed Practical Nurse | Reported Resident #3 fell while on break and became unresponsive |
| Director of Nursing | Director of Nursing (DON) | Provided documents for visual accountabilities and fall scene investigation |
| Staff D | Administrator | Expected care plans to reflect residents' current needs and provide guidance |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 4
Oct 5, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey to assess compliance with federal regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including failure to ensure safe transfer techniques for residents, improper disposal and storage of narcotic medications, unsanitary conditions in the kitchen ice machine, and inadequate infection prevention and control practices.
Deficiencies (4)
| Description |
|---|
| Failure to ensure safe transfer techniques for Resident #22 using a sit to stand mechanical lift. |
| Failure to properly dispose of narcotic medications and maintain accurate drug records for Residents #91 and #36. |
| Failure to keep the ice machine clean and sanitary, with dirt spots found inside the machine. |
| Failure to establish and maintain an infection prevention and control program, including inadequate hand hygiene practices by staff. |
Report Facts
Census: 40
Narcotic tablets found: 60
Deficiency correction date: Correction date listed as 11/3/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 19, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance for certification.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective September 30, 2022.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 5
Aug 25, 2022
Visit Reason
The inspection was an annual recertification survey with complaint intakes #104550-C and 103778-C.
Findings
The facility was found deficient in multiple areas including failure to prevent falls due to inadequate supervision and assistance, inappropriate use of antibiotics without adequate indication, medication administration errors related to insulin timing and technique, and improper storage and labeling of drugs and biologicals.
Complaint Details
Complaint #103778 was substantiated. Complaint #104550 was not substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to utilize interventions to prevent falls for Resident #36, including not providing two-person assistance during transfers as required by the care plan. |
| Failure to ensure appropriate use of antibiotic therapy for Resident #34, including treatment despite negative urine culture results. |
| Failure to follow physician's order for insulin administration timing for Resident #30, administering insulin before meal instead of with meal. |
| Failure to prime insulin pen before administration for Resident #30. |
| Failure to store medications and biologicals securely and properly, including unlocked medication refrigerator, lack of temperature monitoring, and storing discontinued controlled substances with current medications. |
Report Facts
Resident census: 38
Sample size: 12
Falls: 3
Antibiotic doses: 10
Hydrocodone tablets: 23
Fentanyl patches: 3
Ativan remaining: 17.5
Morphine remaining: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed plan of correction |
| LPN 1 | Confirmed staff education and care plan noncompliance related to Resident #36 falls | |
| LPN 2 | Observed medication administration errors for Resident #30 and medication cart issues | |
| RN 1 | Registered Nurse | Confirmed medication administration errors and care plan expectations |
| Director of Nursing (DON) | Confirmed expectations for care plan adherence, medication administration, and storage deficiencies | |
| Clinical Manager (CM) | Registered Nurse | Verified medication refrigerator issues and storage deficiencies |
| Physician Assistant (PA) | Prescribed antibiotic for Resident #34 and explained rationale | |
| Infection Preventionist (IP) | Discussed antibiotic stewardship and UTI diagnosis criteria | |
| Pharmacist | Provided information on insulin administration and medication storage |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 3
Feb 11, 2021
Visit Reason
The inspection visit was conducted as part of the facility's annual health survey and investigation of complaint 95207-C.
Findings
The facility was found deficient in developing and implementing accurate baseline care plans, ensuring professional standards in services provided, and maintaining proper food sanitation practices. Specific issues included incomplete baseline care plans for residents, failure to supervise medication self-administration, and inadequate sanitization of food service ware.
Complaint Details
Complaint 95207-C was substantiated as part of the investigation during the annual survey.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure an accurate completion of the baseline care plan by not listing the resident's high risk medications and their side effects. | SS=D |
| Failure to ensure professional standards were maintained by leaving the resident's medications at the dining room table to self-administer without supervision. | SS=D |
| Failure to assure proper sanitization of the food service ware; the sink used to sanitize pots and pans failed to have sanitizer in the water and documentation showed it had been that way for several days. | SS=E |
Report Facts
Resident census: 39
Admission date: Jan 27, 2021
Medication administration dates: Feb 9, 2021
Sanitizer concentration test results: 0
Sanitizer log entries: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed the Plan of Correction and is referenced as Administrator. |
| Staff E | Registered Nurse (RN) | Observed passing medications and interviewed regarding medication administration. |
| Staff D | Licensed Practical Nurse (LPN) | Observed passing medications and educated on medication administration. |
| Director of Nursing | Interviewed regarding baseline care plans and medication policies. | |
| Clinical Nurse Manager/Assistant Director of Nursing | Interviewed regarding review of baseline care plans. | |
| Dietary Manager | Interviewed regarding food sanitation and sanitizer testing procedures. | |
| Staff A | Dietary Aide | Observed washing dishes and sanitizer testing. |
| Staff B | Dietary Aide | Observed washing pots and pans and sanitizer testing. |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Nov 18, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 45
Inspection Report
Routine
Census: 52
Deficiencies: 0
Oct 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Resident Census: 52
Inspection Report
Routine
Census: 49
Deficiencies: 0
Jun 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 49
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