Elliott Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Elliott Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Apr 20, 2024

  Based on observation, interview, record review, review of the facility's policy, review of manufacturer's guidelines, and review of the Environmental Protection Agency (EPA) disinfectant registry, the facility failed to ensure staff cleaned and disinfected the blood glucose monitor (glucometer) after obtaining a blood glucose reading on 1 of 7 residents who shared the glucometer on the 100 hall, to include Resident (R57) and R24. On 04/18/2024 at 6:05 PM, the survey team provided a copy of the Immediate Jeopardy (IJ) Template to the Executive Director and notified her that staff failure to disinfect the glucometer after obtaining Resident 57's blood glucose measurement constituted IJ at 42 CFR S483.80 F880 Infection Prevention & Control. […]

• Immediate jeopardy, isolatedF600May 4, 2022

  Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were protected from sexual abuse and failed to develop policies, procedures, and protocols that identified when, how, and by whom determinations of capacity to consent to sexual contact would be made and where this determination would be recorded for three (3) of nineteen (19) sampled residents (Residents #68, #13, and #63). Review of the Facility's Allegation Report and Investigation, dated 01/08/2022, revealed Licensed Practical Nurse (LPN) #2 heard Resident #13 making pleasurable noises in the community room near the nursing station. […]

• Immediate jeopardy, isolatedF657May 4, 2022

  Based on interview, record review, and review of the Centers for Medicare and Medicaid's (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to have an effective system in place to ensure care plans were reviewed and revised for two (2) of nineteen (19) sampled residents (Resident #13, Resident #63 and Resident #68). Residents #13 and #68 had a sexual encounter in the facility's family room, on 01/08/2022, which was witnessed by Licensed Practical Nurse (LPN) #2. Resident #13 was overheard making pleasurable sounds in the family room, and LPN #2 observed Resident #68 quickly removing his/her hand from Resident #13's pajama pants. The residents were separated, and the facility initiated an investigation. […]

• Actual harm, isolatedF656Apr 20, 2024

  Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop and implement comprehensive, person-centered care plans for 2 of 31 sampled residents, Resident (R) 9 and 65. R9 developed a facility acquired stage 3 pressure ulcer. Observation and documentation revealed R9 was not repositioned routinely as per the intervention on the care plan. R65 expressed a preference for taking her blood pressure medication at 8:00 AM. However, the resident stated she often did not receive it until two to three hours later. […]

• Actual harm, isolatedF686Apr 20, 2024

  Based on observation, interview, record review, and review of the American Nurse Journal, the facility failed to ensure residents received care consistent with professional standards for 1 of 4 sampled residents (Resident (R) 9) who were at risk for developing pressure ulcers. R9 developed a stage 3 pressure ulcer, and staff failed to turn and repostion the resident every two hours to prevent the pressure ulcer. (Cross Reference F656) The findings include: In an interview on 04/19/2024 at 5:44 PM, the Executive Director stated the facility did not have a policy on skin care and pressure ulcer prevention. […]