Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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 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.
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 | — | 0 | 0 |
| Elmhurst Rehabilitation And Healthcare Center | 2.2 mi | — | 10 | 1 |
| Scandinavian Home Inc | 2.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.