Elmwood Care Center
ELMWOOD CARE CENTER in BERKELEY, CA — inspection on November 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a phone interview on 9/30/25 at 10:50 a.m. with LTCO 1, LTCO 1 confirmed they did not receive notifications of the alleged abuse of Resident 1 and Resident 2. LTCO 1 stated they checked their records found no documentation or reports related to the alleged incidents.During a record review of the facility's policy and procedure (P&P), titled Abuse Investigation and Reporting, dated March 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies.and thoroughly investigated by facility management.
Findings of abuse investigations will also be reported.Role of the Administrator.1. If an incident of resident abuse.neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual.The Administrator will ensure any further potential abuse.Role of the investigator.3.
The investigator will notify the ombudsman that an abuse is being conducted.
The ombudsman will be invited to participate in the review process.Reporting.1.
All alleged violations involving abuse.including injuries of an unknown source.will be reported by the facility Administrator, or his/her designee to the following agencies.a.
The State licensing/certification agency.b.
The local/State Ombudsman.2.
Suspected abuse, neglect, .or mistreatment (including injuries of unknown source.) will be reported within two hours.If the events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made in twenty-four hours.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Elmwood Care Center
2829 Shattuck Avenue Berkeley, CA 94705
SUMMARY STATEMENT OF DEFICIENCIES
Based on interviews and record reviews, the facility failed to ensure a thorough investigation was conducted and completed within five working days following an allegation of abuse for one sampled resident (Resident 2) and the facility did not not have an investigation summary documenting the findings and result of the investigation.This failure had the potential for the allegation of abuse to remain uninvestigated and placed Resident 2 at risk for ongoing abuse due to the absence of protective interventions and corrective actions.
During a record review of Resident 2's admission Record (AR), printed on 9/29/25, the AR indicated Resident 2 was admitted to the facility in December 2024 with diagnoses of cellulitis (skin infection) of abdominal wall and ileostomy status (presence of an opening in the stomach where waste comes out into a bag.
During a record review of Resident 2's SBAR (Situation, Background, Appearance, Review and Notify) record, dated 1/27/25, the SBAR record indicated Resident 2 verbalized that a Certified Nurse Assistant (CNA) was verbally inappropriate and rude towards Resident 2. SBAR showed Resident had verbalized that the CNA told her, You're here because God doesn't like you.
During an interview on 9/29/25 at 11:39 a.m. with the Infection Preventionist (IP) also Director of Nursing designee, IP stated they were unable to locate the investigation summary for Resident 2. IP stated the investigation summary should have been done and completed within five working days to ensure there was sufficient time to conduct a thorough investigation of the alleged abuse.
The IP further stated she could not determine what transpired during the investigation because there was no documentation showing the findings or results of the investigation.
During an interview on 9/29/25 at 2:36 p.m. with the Administrator (ADM), ADM stated if there was an allegation of abuse, an investigation would be conducted. ADM stated she would also notify the State Survey Agency, Long-Term Care Ombudsman (LTCO) and the Police Department immediately or within 24 hours, as required by regulation, to rule out abuse. ADM stated she had five working days to complete a thorough investigation of an allegation of abuse. ADM stated it was important to have the investigation summary completed to ensure no other residents had experienced the same allegation of abuse and to ensure the residents involved were protected from further harm.During a record review of the facility's policy and procedure (P&P), titled, Abuse Investigation and Reporting, dated March 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies.and thoroughly investigated by facility management.
Findings of abuse investigations will also be reported.6.
The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the abuse.
Facility ID: