Ellis Nursing Home (the)

Inspectors wroteBased on observation, record review and interviews the facility failed to identify and assess the use of an abdominal binder (wide compression belt that encircles the abdomen and is secured into place) as a potential physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) for one Resident (#8) of 26 sampled residents.

Inspectors wroteBased on document review and interview the facility failed to ensure medical records were complete and accurate, containing evidence of completed pharmacy recommendations for review by the Pharmacy consultant monthly to verify recommendation completion for one Resident (#1) out of a total sample of 26 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the call bell system was functioning properly in his/her room, when on 12/06/25 after family members complained his/her call light was not working, it was determined that the reset button had been taped down disabling the ability for the call light to function properly.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents, (Resident #1) who was re-admitted with multiple pressure injuries, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice related to timely follow-up on provider recommendations for wound care and accurate transcription of treatment orders.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment, the Facility failed to ensure Resident #1 was free from the use of a physical restraint, when on 05/06/25, Certified Nurse Aide (CNA) #1 used a sheet to restrain Resident #1 in his/her wheelchair to prevent him/her from falling.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who, on 05/06/25, had been restrained in his/her wheelchair by Certified Nurse Aide #1, the Facility failed to ensure Administration reported the alleged incident to the Department of Public Health (DPH) within two hours as required, when although the Director of Nurses was aware on 05/06/25, the Facility did not report the use of the restraint to DPH until 05/12/25, (almost a week later).

Inspectors wroteBased on observations and interviews, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure effective hand hygiene practices and appropriate PPE (personal protective equipment) were utilized when entering in and exiting out of resident rooms, including residents on transmission-based precautions; and 2. Ensure resident hand hygiene was implemented during meal service.

Inspectors wroteBased on document review, observation, and interview, the facility failed to develop, implement, and individualize comprehensive plans of care for two Residents (#126, #109), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #126, to develop and implement a care plan for the Resident's biliary drains (tubes inserted in the bile ducts to treat a blockage) and portacath (a type of central venous line that is surgically inserted beneath the skin and leads into the heart that is used to administer intravenous (IV) fluids and medications and to take blood samples); and 2. For Resident #109, to ensure the Resident's skin care plan addressed the Resident's current skin condition of a heel pressure ulcer.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen was maintained in a sanitary and safe condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#31), out of a total sample of 25 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure specialty eye appointments were scheduled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two Residents (#23, #110), in a sample of 25 residents, were seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Specifically, the facility failed: 1. For Resident #23, to ensure the Resident was seen by the Physician at least every 120 days after the first 90 days after admission; and 2. For Resident #110, to ensure the Resident was seen by the Physician at least every 120 days after the first 90 days after admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent a decline in range of motion causing the development of bilateral hand contractures (shortening and hardening of tissues leading to rigidity of joints) for one Resident (#52), out of a total sample of 26 residents.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed for five Residents (#109, #37, #106, #52, and #70), out of 26 sampled residents, to develop and implement individualized resident-centered care plans to meet the residents' needs. Specifically, the facility failed: 1. For Resident #109, to implement the care plan for the use of cushioned floor mats at the bedside as a fall intervention; 2. For Resident #37, to consistently implement the care plan for the use of a right-hand Carrot (orthotic device in the shape of a carrot used to prevent worsening hand contracture); 3. For Resident #106, to develop a care plan for the use of long term antibiotics/urinary tract infection (UTI) prophylaxis; 4. For Resident #52, to develop a care plan to include goals and interventions for a Resident with limited range of motion; and 5. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products and maintain safe and clean equipment in four of four nourishment kitchenettes.

Inspectors wroteBased on observation, interview, and policy review, the facility failed: 1. To ensure transmission-based precautions (TBP), specifically contact precautions, were implemented according to Centers for Disease Control and Prevention (CDC) guidance, for one Resident (#44), out of three sampled residents; and 2. To ensure staff implemented infection control practices and performed hand hygiene when performing wound care.

Inspectors wroteBased on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to: 1. Ensure monitoring of antibiotic use that did not meet criteria for antibiotic treatment was completed for three Residents #291, #61, and #78, out of a total sample of 26 residents; and 2. Ensure a stop date or clinical rationale was provided for continued use of an antibiotic for one Resident #20, out of a total sample of 26 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure Resident #70 was provided with a dignified dining experience.

Inspectors wroteBased on interviews, review of grievance documentation, and policy review, the facility failed to formulate a grievance timely for concerns brought forward by Resident #6 regarding missing hearing aids.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#106, #107, and #52), out of 26 sampled residents. Specifically, the facility failed: 1. For Resident #106, to ensure the use of bed and chair alarms were coded on the MDS; 2. For Resident #107, to accurately document the use of chair and bed alarms on the MDS; and 3. For Resident #52, to identify bilateral hand contractures (shortening and hardening of tissues leading to rigidity of joints) on the MDS.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#10), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication were utilized for one Resident (#86), in a total sample of 26 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one Resident (#28), in a sample of 26 residents, had been seen by a physician every 30 days for the first 90 days of admission.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#20), out of a total sample of 26 residents. Specifically, the facility failed to ensure that the January 2024 and February 2024 consultant pharmacist's recommendations were acted upon in a timely manner to ensure there was a stop date for Bactrim (an antibiotic medication).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure for one Resident (#20), out of a total sample of 26 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure an antibiotic was administered for the appropriate duration and with adequate indications for use.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for one Resident (#15) that their as needed (PRN) psychotropic medication, Ativan, was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice. The total sample was 26 residents.

Inspectors wroteBased on observation, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, for one Resident (#1), of a total of 7 residents infected with COVID-19, from one of two units with COVID-19 cases, the facility failed to ensure appropriate signage was visible and staff used appropriate Personal Protective Equipment while providing care to a COVID-19 positive resident.