Inspection Reports for Elmhurst Rehabilitation & Healthcare Center

Deficiencies were identified related to professional standards of care, medication administration, central venous catheter care, and quality of care including medication errors and oral care. The facility submitted a Plan of Correction (POC) addressing these issues with a completion date of February 3, 2026.

Deficiencies were identified related to professional standards of care, medication administration errors, quality of care including central venous catheter care, oral care, and medication error rates exceeding 5%. No life safety code deficiencies were identified.

The complaint investigation was substantiated based on surveyor observations, clinical record review, staff and resident interviews, and facility incident investigation. Staff B received a verbal notice for employee conduct violations including unsatisfactory performance, insubordination, and disrespectful conduct.

The facility failed to treat a resident with respect and dignity, as evidenced by staff being rude and disrespectful to the resident, including refusing to provide the resident's phone and causing the resident to fear for their safety. Interviews and record reviews confirmed the inappropriate conduct by staff members.

Complaint submitted on 10/8/2025 alleging improper care of Resident ID #1's wound; substantiation indicated by findings of delayed wound care implementation.

The facility failed to provide necessary surgical wound treatment for Resident ID #1 upon admission on 9/12/2025, resulting in approximately three days without wound care orders. Interviews with staff confirmed the wound care orders were not implemented until 9/15/2025.

Deficiencies were identified related to resident rights, comprehensive care plans, quality of care, medication errors, food safety, and resident call systems. The facility failed to meet several regulatory requirements including dignity and respect for residents, proper documentation and execution of physician orders, medication administration accuracy, food safety compliance, and ensuring residents' call lights were within reach.

Deficiencies were identified related to resident rights, services meeting professional standards, quality of care, medication error rates, food safety, and resident call system. No Life Safety Code deficiencies were found. The facility was found to be in compliance with emergency preparedness requirements.

The facility was found deficient in multiple areas including failure to treat a resident with dignity related to incontinence care, failure to follow physician orders for fluid intake and dietary restrictions, failure to monitor daily weights as ordered, medication administration errors exceeding 5%, improper food storage and sanitation in the kitchen, and failure to ensure call lights were accessible to residents.

The complaint alleged that a resident was physically abused by another resident and that a resident left the facility without proper discharge procedures, resulting in delayed response and lack of notification to authorities.

The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm including a bloody nose and bruising. Additionally, the facility failed to ensure safe and orderly discharge procedures for a resident who left the facility against medical advice, including lack of discharge planning, medication reconciliation, and notification of elopement to police. Medication administration records were inaccurately documented for the resident who left.

The facility was found deficient in multiple areas including failure to ensure residents' communication needs were met, incomplete baseline care plans, inadequate medication administration and monitoring, lack of follow-up on medical appointments, insufficient wound care documentation, failure to provide safe dialysis pharmaceutical services, incomplete bed rail assessments and consents, and lapses in infection prevention and control practices related to contact precautions.

The visit was triggered by complaints referenced as ACTS numbers 99336 and 99380. The complaint investigation found substantiated deficiencies related to resident rights, communication, care planning, medication administration, and infection control.

Deficiencies were identified related to resident rights, comprehensive care plans, professional standards of care, quality of care, bed rails, infection control, medication administration, emergency preparedness, and life safety code compliance. Specific issues included failure to ensure residents' communication needs, incomplete baseline care plans, missed medication doses, inadequate wound care documentation, and failure to conduct required fire drills.

The complaint alleged that a cancer medication (Abiraterone Acetate) was given to the wrong resident for 14 days. The investigation confirmed that Resident ID #1, who does not have prostate cancer, received the medication intended for Resident ID #2, who has prostate cancer, from 12/21/2024 through 1/2/2025. The transcription error and failure to identify the medication irregularity placed Resident ID #1 at risk for serious harm.

The facility failed to ensure that medication irregularities were identified by the pharmacist during the monthly drug regimen review, resulting in Resident ID #1 receiving Abiraterone Acetate, a medication intended for another resident with prostate cancer, for 13 days. Multiple staff members failed to verify the correct resident before administering the medication, and the facility failed to implement effective medication auditing per their QAPI plan.

Complaint submitted to the Rhode Island Department of Health on 12/17/2024 alleging Resident ID #2 failed to receive care for 24 hours. The complaint was substantiated by surveyor observations and interviews.

The facility failed to provide sufficient nursing staff to assure resident safety related to call light response for Resident ID #4. It was observed and confirmed through interviews that call lights were not answered timely, with one instance taking 36 minutes for staff to respond.

Complaint received by Rhode Island Department of Health on 2024-08-19 alleging Resident ID #39 received medication for 3 days without consent.

The facility failed to honor a resident's right to refuse treatment by administering Trazodone as a scheduled medication despite the resident's refusal. The facility also failed to follow physician orders for medication administration and lab tests for several residents, did not implement gradual dose reductions for psychotropic medications timely, failed to provide appropriate wound care and pressure ulcer prevention for a resident with diabetic ulcers, did not ensure continence care and catheter management, failed to provide timely pain management, and did not assist a resident in obtaining dental services.

The complaint investigation was substantiated with findings including failure to honor resident rights, improper medication administration, and inadequate treatment of diabetic ulcers and pressure ulcers.

The survey identified Immediate Jeopardy related to quality of care for diabetic ulcers and failure to provide treatment and care for residents. Additional deficiencies were found related to residents' rights, comprehensive care plans, medication administration, skin integrity, pain management, dental services, and life safety code compliance.

The complaint alleged that Resident ID #39 received medication (Trazodone) for three days without consent. The investigation confirmed the medication was administered routinely despite the resident's refusal and lack of consent.

The facility failed to honor a resident's right to refuse treatment by administering Trazodone without consent for three days. Additionally, the facility failed to provide appropriate continence care and urinary tract infection prevention for a resident who was continent on admission, and failed to provide appropriate catheter care and follow-up for residents with suprapubic catheters.

The facility failed to ensure nursing staff completed mandatory IV competency training, resulting in improper care of a resident's PICC line and subsequent hospital transfer. Additionally, the facility did not maintain an effective infection prevention and control program for a resident positive for MRSA, failing to place the resident on contact precautions until after surveyor intervention.

The visit included a complaint investigation referenced by ACTS number 94719. The complaint involved issues such as pressure ulcer care, smoking/vaping policy violations, infection control, and medication administration errors. The complaint was substantiated as deficiencies were cited.

Deficiencies were cited related to pressure ulcers, accident hazards, infection control, medication administration, and life safety code violations. The facility failed to ensure proper treatment and documentation for residents with pressure ulcers, adequate supervision to prevent accidents, infection prevention and control, and medication safety. Life safety code deficiencies were also identified in the kitchen fire suppression system and environmental conditions.

The facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care. Specifically, one resident's PTSD diagnosis was not identified in comprehensive assessments, and the care plan did not address trauma-informed care or interventions to mitigate re-traumatization triggers until updated after surveyor intervention.

Complaint investigation triggered by community reported complaint alleging Resident ID #1 was administered his/her roommate's methadone dose, resulting in opioid overdose and hospitalization. Resident ID #2 reported missing methadone dose and experiencing withdrawal symptoms. Facility investigation was inconclusive due to lack of lab confirmation and conflicting staff reports.

The facility failed to ensure residents were free from significant medication errors, resulting in one resident receiving another's methadone dose causing an opioid overdose requiring hospitalization, and another resident missing a methadone dose without assessment for withdrawal symptoms. The investigation was inconclusive regarding the exact administration but identified systemic issues including staff unfamiliarity and bed assignment confusion.

Deficiencies were cited related to comprehensive care plans, treatment and services to prevent pressure ulcers, free of accident hazards, competent nursing staff, drug regimen review, food safety, resident records, and infection prevention and control. The facility submitted a Plan of Correction (POC) addressing these deficiencies with corrective actions and timelines.

The facility was found deficient in multiple areas including failure to follow physician's medication orders, inadequate pressure ulcer care and documentation, insufficient supervision to prevent accidents, failure to act on pharmacist medication regimen review recommendations, improper storage of expired medications, inadequate food service safety practices, failure to maintain controlled substances records properly, and failure to ensure staff wore appropriate PPE for COVID-19 positive residents.

The complaint alleged that Resident ID #2's family supplies the resident's medication and was not notified in advance when refills were needed, resulting in missed medications. The investigation confirmed multiple medication administration errors and failures to follow physician orders for residents #1, #2, and #3.

The facility failed to ensure appropriate medication administration for multiple residents, including unnecessary duplicate dosing of pantoprazole for one resident, missed doses of critical medications for others, and failure to follow physician orders for prednisone taper, Metoprolol, and Midodrine. The Director of Nursing Services was unable to provide evidence that medications were administered as ordered.

The complaint was submitted by the resident's family member alleging the resident was deprived of water and bathroom access by the overnight nurse and was instructed by a CNA to urinate in his/her brief. The complaint was substantiated by interviews and record review.

The facility failed to treat a resident with respect and dignity, as evidenced by staff instructing the resident to urinate in his/her brief. The Regional Director of Nursing Services acknowledged this was not accepted practice and could not provide evidence that the resident was treated with respect and dignity.

The complaint investigation was triggered by an incident where Resident ID #1 sustained a left arm fracture during an improper transfer using a sit to stand lift. The resident also received Nitroglycerin without a physician's order despite contraindicated vital signs, and there were concerns about inadequate supervision and catheter care.

The facility failed to ensure a safe environment free from accident hazards, resulting in a resident's left arm fracture during transfer. Additionally, the facility failed to provide adequate supervision regarding used insulin syringes and failed to ensure appropriate catheter care for another resident. The facility also failed to ensure licensed nurses had the necessary competencies, including administering Nitroglycerin without a physician's order and improper resident positioning during anticipated CPR.

The complaint investigation was triggered by allegations including failure to implement a resident's fluid restriction and medication errors. Immediate Jeopardy was identified but removed after corrective actions and staff education.

The facility was found to have multiple deficiencies including failure to implement a resident's ordered fluid restriction, failure to ensure residents are free from physical restraints and abuse, inaccurate assessments, failure to provide necessary ADL care, medication errors, inadequate infection control, and failure to maintain proper documentation and policies. Immediate Jeopardy was identified but removed after corrective actions.

The complaint investigation revealed that a nurse administered ear drops into a resident's eye causing pain and irritation. Other findings included failure to administer prescribed antibiotics and inhalers, and missed medication doses. Interviews with staff and family members confirmed these issues.

The facility failed to ensure that a physician reviewed the resident's total program of care at each visit for one resident. Additionally, significant medication errors were identified, including administration of ear drops into a resident's eye, failure to administer prescribed antibiotics and inhalers, and missed medication doses for multiple residents.

The complaint alleged that Resident ID #1 was re-hospitalized due to respiratory failure exacerbated by lack of BiPAP availability at the facility. The investigation confirmed administration of BiPAP and oxygen therapy without physician orders.

The facility failed to ensure that Resident ID #1 received necessary respiratory care, including BiPAP and oxygen therapy, in accordance with professional standards. Both therapies were administered without physician orders or appropriate documentation of settings.