Inspection Reports for
Elm Crest Senior Living Community

Complaints #2735837-C and #2745290-I and #2745290-M were investigated. The complaint #2745290-M was investigated by a Department representative and a Memo was submitted for review.

The facility failed to ensure adequate supervision and fall prevention measures for Resident #1, resulting in multiple falls and bruises. The facility had policies and procedures but failed to consistently implement them, leading to resident injuries and delayed reporting.

The facility failed to follow its fall policy and protocol by not timely notifying the charge nurse and completing an assessment after Resident #1 had a fall. Staff did not report the fall immediately, and Resident #1 was found on the floor with bruises of unknown origin. Multiple staff interviews revealed inconsistent reporting and failure to follow procedures. The resident was sent to the Emergency Department for evaluation and diagnosed with bruising, a minor head injury, and a urinary tract infection. The facility added interventions such as a fall mat and not leaving the resident alone on the commode.

Based on acceptance of the credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective February 12, 2026.

The facility failed to maintain proper food temperatures during service, served meals not consistent with residents' therapeutic diet orders, and did not maintain a clean and sanitary kitchen environment. Multiple observations and interviews revealed issues with cold food, incorrect diet modifications, dirty kitchen equipment, missing cleaning logs, and structural deficiencies such as a missing ceiling tile and water leakage.

The facility was cited for multiple deficiencies including failure to maintain food temperatures, failure to serve meals according to residents' specific dietary needs, and failure to maintain a sanitary kitchen environment. Corrective actions and systemic changes were planned and implemented to address these issues.

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.

The investigation was complaint-related, focusing on the fall of Resident #4 on 9/12/25 due to improper transfer by one staff instead of two as required. The resident had a history of falls and required two-person assistance. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure safe transferring techniques for Resident #4, who had multiple falls and required two staff assistance during transfers. On 9/12/25, the resident fell while being transferred with only one staff member, contrary to care plan and therapy recommendations.

All deficiencies were corrected and the facility is in substantial compliance effective December 3, 2024.

The complaint investigation was triggered by allegations of resident mistreatment, incomplete assessments, inadequate care planning, unsafe mobility assistance, fall-related injuries, improper respiratory care, food sanitation concerns, and infection control failures. The investigation substantiated multiple deficiencies in these areas.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, incomplete Minimum Data Set assessments, inadequate care planning for MRSA, failure to provide appropriate mobility assistance, unsafe transfer techniques leading to resident falls and injuries, improper respiratory care including nebulizer maintenance, inadequate dishwashing sanitation, and failure to implement proper infection prevention and control measures including Enhanced Barrier Precautions.

Complaint #124258-C was not substantiated. Facility reported incident #123797-I was substantiated.

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.

The facility failed to use safe transfer techniques for one of three residents, resulting in a fall with bruising and skin tears. The facility also failed to implement new interventions to reduce repeat falls for the resident.

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.

The facility failed to review and revise care plans to reflect residents' current status for 4 residents and failed to provide needed services in accordance with professional standards by not completing assessments after falls with major injury for 2 residents. Additionally, the facility did not follow protocol for transferring a resident after a fall using a full body lift.

Facility reported incidents #119835-I and #121288-I were not substantiated. Incident #121671 was substantiated.

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.

The facility was found deficient in safe transfer techniques for a resident requiring mechanical lift assistance, failure to dispose of discontinued narcotic medications for two residents, inadequate cleaning of the ice machine, and failure of staff to practice proper hand hygiene during meal service.

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.

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.

Complaint #103778 was substantiated. Complaint #104550 was not substantiated.

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 95207-C was substantiated as part of the investigation during the annual survey.

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.

The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.