Inspection Reports for Elmhurst Rehabilitation & Healthcare Center
RI, 02908
Back to Facility Profile
Inspection Report
Plan of Correction
Census: 185
Capacity: 206
Deficiencies: 5
Jan 15, 2026
Visit Reason
A recertification and complaint survey was conducted from 01/12/2026 through 01/15/2026 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
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.
Severity Breakdown
Level D: 3
Level E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure residents received treatment and care in accordance with professional standards for 3 of 3 residents reviewed for medication administration and physician's orders. | Level D |
| Failure to flush gastrostomy tube as ordered and administer medications at proper times for residents with G-Tubes. | Level D |
| Failure to ensure proper care and documentation of central venous catheters (CVCs) and PICC lines for 3 residents, including measurement of catheter length and dressing changes. | Level E |
| Failure to provide adequate oral care for residents, including those with G-Tubes, resulting in poor oral hygiene and malodor. | Level E |
| Medication error rate exceeded 5 percent for 2 residents, with an error rate of 7.41%. | Level D |
Report Facts
Facility Census: 185
Total Capacity: 206
Medication Error Rate: 7.41
Medication Opportunities Observed: 27
Medication Errors: 2
Inspection Report
Annual Inspection
Census: 185
Capacity: 206
Deficiencies: 4
Jan 15, 2026
Visit Reason
A recertification and complaint surveys were conducted at Elmhurst Rehabilitation and Healthcare Center from 01/12/2026 through 01/15/2026 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities. State licensure and emergency preparedness surveys were also conducted.
Findings
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.
Severity Breakdown
Level D: 2
Level E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, including failure to follow physician's orders for flushing gastrostomy tubes and timely medication administration. | Level D |
| Facility failed to ensure residents receive treatment and care in accordance with professional standards related to central venous catheter care and dressing changes. | Level E |
| Facility failed to ensure proper oral care for residents, resulting in thick brown coating and malodorous breath. | Level E |
| Facility failed to ensure medication error rates are below 5%, with observed medication errors resulting in a 7.41% error rate. | Level D |
Report Facts
Facility Census: 185
Total Capacity: 206
Medication Administration Opportunities: 27
Medication Error Rate: 7.41
Medication Errors: 2
Inspection Report
Follow-Up
Deficiencies: 0
Sep 22, 2025
Visit Reason
An off-site desk audit was conducted on September 22, 2025, to review all previous deficiencies cited on July 31, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Jul 31, 2025
Visit Reason
The document is a Plan of Correction (POC) filed by Elmhurst Rehabilitation and Healthcare Center following recertification and complaint surveys conducted from 07/28/2025 through 07/31/2025 to address identified deficiencies.
Findings
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.
Severity Breakdown
D: 4
F: 1
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to treat resident with respect and dignity, specifically Resident ID #18 was not treated with dignity regarding incontinence care. | D |
| Failure to ensure residents receive treatment and care in accordance with professional standards, including inadequate management of fluid intake and physician orders for Resident IDs #1 and #103. | D |
| Failure to ensure quality of care, including inadequate monitoring and documentation of daily weights for Resident ID #192. | D |
| Medication error rates exceeded 5 percent, with errors involving Resident IDs #24 and #135. | D |
| Failure to comply with food safety regulations, including improper dating of food items and accumulation of pink substance on ice dispenser shield. | F |
| Failure to ensure resident call lights were within reach for Residents IDs #1, 105, 162, and 175. | E |
Report Facts
Deficiencies cited: 6
Medication error rate: 10.71
Dates of survey: 4
Resident IDs referenced: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Observed escorting resident and involved in dignity and incontinence care deficiency. |
| Staff B | Licensed Practical Nurse | Involved in medication administration and physician order issues. |
| Staff F | Nurse Practitioner | Authored progress notes and involved in quality of care deficiency. |
| Staff I | Licensed Practical Nurse | Involved in medication administration observations. |
| Staff J | Activity Aide | Acknowledged resident call light was out of reach. |
| Staff K | Nursing Assistant | Acknowledged resident call light was on the floor and out of reach. |
| Director of Nursing Services | Director of Nursing (DNS) | Responsible for executing corrective action plans and audits. |
Inspection Report
Annual Inspection
Census: 181
Capacity: 206
Deficiencies: 6
Jul 31, 2025
Visit Reason
The annual Federal Life Safety Code survey and recertification and complaint surveys were conducted to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Findings
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.
Severity Breakdown
D: 4
F: 1
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to treat each resident with respect and dignity related to incontinence care prior to leave of absence. | D |
| Failure to ensure residents receive treatment and care in accordance with professional standards for urology consult and dietary restrictions. | D |
| Failure to ensure residents receive treatment and care in accordance with professional standards for daily weights monitoring. | D |
| Medication error rate exceeded 5%, with a 10.71% error rate involving two residents. | D |
| Failure to ensure food safety requirements including proper labeling and sanitation in the kitchen. | F |
| Failure to ensure residents can call for staff assistance through a communication system; call lights were out of reach for multiple residents. | E |
Report Facts
Capacity: 206
Census: 181
Medication error rate: 10.71
Medication error opportunities: 28
Medication errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician | Observed escorting resident and involved in incontinence care deficiency |
| Staff B | Licensed Practical Nurse | Entered physician's order for fluids and involved in medication error deficiency |
| Staff C | Nurse Practitioner | Interviewed regarding urology consult and physician orders |
| Staff D | Nursing Assistant | Interviewed regarding meal ticket and dietary restrictions |
| Staff E | Registered Nurse | Acknowledged diet order instructions |
| Staff F | Nurse Practitioner | Authored progress note on weight monitoring |
| Staff H | Licensed Practical Nurse | Observed medication administration with errors |
| Staff I | Licensed Practical Nurse | Observed medication administration with errors |
| Director of Nursing Services | DNS | Interviewed regarding resident care and medication administration |
| Food Service Director | FSD | Interviewed regarding food safety deficiencies |
| Staff J | Activity Aide | Acknowledged resident call light out of reach |
| Staff K | Nursing Assistant | Acknowledged resident call light out of reach |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 7, 2025
Visit Reason
A follow-up to a previous recertification survey exit dated 2/6/2025 was conducted at this facility from 3/6/2025 through 3/7/2025.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Complaint Investigation
Census: 178
Capacity: 206
Deficiencies: 9
Feb 6, 2025
Visit Reason
A recertification and complaint survey was conducted at Elmhurst Rehabilitation & Healthcare Center from 2/3/2025 through 2/6/2025 to determine compliance with federal regulations for Long Term Care Facilities, including State Licensure and Emergency Preparedness surveys.
Findings
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.
Complaint Details
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.
Severity Breakdown
Level D: 4
Level E: 4
Level G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Resident rights not ensured for communication and access to services for Resident ID #333. | Level D |
| Baseline care plan not developed within 48 hours of admission and failed to include necessary healthcare information. | Level D |
| Services provided did not meet professional standards for medication administration and wound care. | Level G |
| Quality of care deficiencies including failure to ensure necessary care and services for 4 of 5 residents reviewed. | Level E |
| Dialysis care plan and medication administration deficiencies for Resident ID #43. | Level D |
| Bed rails not properly assessed or used according to federal regulations for multiple residents. | Level E |
| Failure to conduct required fire drills quarterly as per National Fire Protection Association standards. | Level E |
| Infection prevention and control program deficiencies including failure to follow CDC guidance for MDROs and PPE use. | Level E |
| Failure to provide assistive devices and adaptive equipment for residents requiring them. | Level D |
Report Facts
Capacity: 206
Census: 178
Deficiencies cited: 9
Days: 22
Medication administration dates: 22
Fire drills failed: 2
Residents reviewed for bed rails: 26
Inspection Report
Complaint Investigation
Census: 180
Capacity: 206
Deficiencies: 10
Aug 28, 2024
Visit Reason
A Recertification Survey and complaint investigation was conducted at Elmhurst Rehabilitation and Healthcare Center from 8/6/2024 through 8/28/2024 to determine compliance with federal requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
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.
Complaint Details
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.
Severity Breakdown
Immediate Jeopardy: 1
Level G: 4
Level D: 1
Level E: 2
Level H: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to provide treatment and care in accordance with professional standards for diabetic ulcers resulting in worsening wounds and hospitalization for Resident ID #94. | Immediate Jeopardy |
| Failure to honor a resident's right to refuse treatment for Resident ID #39. | Level G |
| Failure to ensure residents receive treatment and care in accordance with professional standards for multiple residents including failure to implement gradual dose reduction for diabetes medications. | Level D |
| Failure to provide treatment and care for diabetic foot ulcers and pressure ulcers for Resident ID #94. | Level G |
| Failure to provide appropriate treatment and services to prevent pressure ulcers for 1 of 4 residents reviewed. | Level G |
| Failure to provide appropriate treatment and services for bowel and bladder incontinence for Resident ID #539 and others. | Level E |
| Failure to provide pain management consistent with professional standards for Resident ID #539. | Level G |
| Failure to ensure psychotropic drug regimen is free from unnecessary drugs for 1 of 6 residents reviewed. | Level H |
| Failure to provide routine and emergency dental services for Resident ID #69. | Level E |
| Failure to maintain minimum 18-inch clearance between sprinkler deflector and stored items in housekeeping closet. | Level G |
Report Facts
Capacity: 206
Census: 180
Deficiencies cited: 10
Dates of medication administration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Bouchard | Administrator | Informed of Immediate Jeopardy and signed Immediate Jeopardy Template on 8/21/2024 |
| Staff A | Nurse Practitioner | Interviewed regarding medication administration and orders |
| Staff K | Nurse Practitioner | Entered medication order for Trazodone |
| Staff H | Registered Nurse | Interviewed regarding resident's skin assessments and medication administration |
| Staff L | Nurse Practitioner | Evaluated resident's wounds and skin impairments |
| Staff M | Registered Nurse | Documented resident's removal of offloading boots |
| Staff D | Nurse Practitioner | Authored progress note on pain management and medication orders |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding medication administration and care plans |
Inspection Report
Follow-Up
Deficiencies: 0
May 2, 2024
Visit Reason
An off-site desk audit was conducted on May 2, 2024, to review all previous deficiencies cited on March 14, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 163
Capacity: 206
Deficiencies: 7
Mar 14, 2024
Visit Reason
A federal recertification survey and complaint investigation was conducted at Elmhurst Rehabilitation & Healthcare Center from 3/10/2024 through 3/14/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
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.
Complaint Details
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 (7)
| Description |
|---|
| Failure to ensure residents at risk for pressure ulcers received necessary treatment and documentation. |
| Failure to ensure adequate supervision and monitoring to prevent accidents related to smoking/vaping. |
| Failure to ensure residents with urinary catheters received appropriate treatment and documentation. |
| Failure to ensure residents are free of significant medication errors. |
| Failure to establish and maintain an infection prevention and control program. |
| Failure to maintain a safe, sanitary, and comfortable environment for residents, including environmental deficiencies in resident rooms. |
| Failure to maintain kitchen fire suppression system in compliance with NFPA standards. |
Report Facts
Resident census: 163
Total capacity: 206
Deficiency count: 7
Resident IDs referenced: 7
Inspection Report
Follow-Up
Deficiencies: 0
Oct 16, 2023
Visit Reason
An off-site desk audit was conducted on October 16, 2023, to review all previous deficiencies cited on September 11, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 10
Sep 11, 2023
Visit Reason
A federal recertification survey and complaint investigation was conducted from 09/05/2023 through 09/11/2023 to determine compliance with Federal and State Laws and Regulations.
Findings
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.
Severity Breakdown
Level D: 8
Level E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to provide care in accordance with a resident's plan of care for 1 of 6 resident care plans reviewed for falls and impaired mobility. | Level D |
| Facility failed to ensure services met professional standards of quality for 1 of 1 resident reviewed related to medications administered via a gastrostomy tube. | Level D |
| Facility failed to provide necessary treatment and services to prevent pressure ulcers for 1 of 7 residents reviewed. | Level D |
| Facility failed to ensure the resident environment remains free of accident hazards for 1 of 6 residents reviewed for falls and 1 of 1 resident reviewed for supervision with meals. | Level D |
| Facility failed to ensure licensed nurses have the specific skill sets necessary to care for residents' needs related to gastrostomy tube care for 1 of 1 resident reviewed. | Level D |
| Facility failed to ensure drug regimen of each resident is reviewed at least monthly by a licensed pharmacist for 2 of 5 residents reviewed. | Level E |
| Facility failed to store and label drugs and biologicals in accordance with professional principles for 2 of 4 medication storage rooms and 1 of 6 medication carts observed. | Level D |
| Facility failed to meet food safety requirements including hair and beard restraints and cleanliness of kitchen fans. | Level D |
| Facility failed to maintain medical records in accordance with professional standards for 1 of 2 residents reviewed related to controlled substances. | Level D |
| Facility failed to establish and maintain an infection prevention and control program to prevent and control infections and communicable diseases. | Level E |
Report Facts
Deficiencies cited: 10
Residents reviewed for falls: 6
Residents reviewed for pressure ulcers: 7
Residents reviewed for medication regimen: 5
Medication storage rooms observed: 4
Medication carts observed: 6
Inspection Report
Follow-Up
Deficiencies: 0
Apr 24, 2023
Visit Reason
A follow-up to a previous recertification survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Complaint Investigation
Census: 180
Capacity: 206
Deficiencies: 12
Mar 24, 2023
Visit Reason
A recertification survey and complaint investigation were conducted from 03/06/2023 through 03/24/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
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.
Complaint Details
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.
Severity Breakdown
Immediate Jeopardy: 1
Severity Level D: 5
Severity Level E: 1
Severity Level F: 1
Severity Level G: 1
Severity Level H: 1
Severity Level I: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to implement a resident's ordered fluid restriction leading to medical emergency and death. | Immediate Jeopardy |
| Failure to ensure residents are free from physical or chemical restraints not required to treat medical symptoms. | Severity Level D |
| Failure to ensure assessments accurately reflect residents' status for catheters, wander guards, and antipsychotic use. | Severity Level E |
| Failure to provide necessary ADL care including nail care for residents. | Severity Level G |
| Failure to provide treatment and care in accordance with professional standards for residents receiving dialysis and other treatments. | Severity Level I |
| Failure to ensure residents are free from significant medication errors. | Severity Level H |
| Failure to maintain laboratory services to meet residents' needs. | Severity Level D |
| Failure to properly store and label drugs and biologicals in medication carts and rooms. | Severity Level F |
| Failure to maintain food safety and sanitary conditions in food service. | Severity Level D |
| Failure to maintain resident medical records accurately and confidentially. | Severity Level D |
| Failure to maintain infection prevention and control program including PPE use and isolation procedures. | Severity Level D |
| Failure to maintain life safety code compliance including sprinkler system maintenance and laundry chute safety. | Severity Level D |
Report Facts
Capacity: 206
Census: 180
Residents reviewed for dialysis: 6
Residents reviewed for medication errors: 1
Residents reviewed for catheter care: 7
Residents reviewed for immunization documentation: 8
Residents reviewed for infection control: 2
Residents reviewed for ADL care: 1
Residents reviewed for assessments: 7
Residents reviewed for restraints: 1
Residents reviewed for medication reconciliation: 8
Residents reviewed for respiratory care: 6
Residents reviewed for food safety: 6
Residents reviewed for medical records: 3
Residents reviewed for infection control: 2
Residents reviewed for life safety: 52
Loading inspection reports...
