Ellis Nursing Home (The)

In the surveyor’s words

From the most serious findings on record at Ellis Nursing Home (The), in the surveyor’s own words.

• Actual harm, isolatedF688Apr 22, 2024

  Based 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. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion (ROM), dated 8/1/23, indicated but was not limited to the following: -As part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his/her joints; limitations in movement or mobility; opportunities for improvement; and previous treatment and services for mobility. […]

• Actual harm, isolatedF686Dec 16, 2022

  Based on observations, interviews, and record review, the facility failed to ensure two Residents (#98 and #88), out of a total sample of 22 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #98, to implement a treatment as ordered and failed to implement effective pressure reduction strategies, resulting in the worsening of a pressure injury; and 2. For Resident #88, to ensure pressure related interventions were consistently implemented to promote wound healing. Findings include: 1. […]

• Actual harm, isolatedF689Dec 16, 2022

  Based on observations, interviews, and record review the facility failed to maintain an environment free of accident hazards for three Residents (#100, #20, and #214), out of a sample of 22 residents. Specifically, the facility failed to ensure: 1. For Resident #100, that effective care plan interventions were developed and implemented to prevent nine falls, one of which resulted in major injury; 2. For Resident #20, staff reduced the risk of future falls by properly implementing fall risk interventions per facility policy; and 3. […]

• No harm, potential for more than minimal, widespreadF880Dec 16, 2022

  Based on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Post proper signage for residents on transmission- based precautions (TBP) to ensure staff were aware of precaution need and implement appropriate use of personal protective equipment (PPE) to enter a COVID-19 positive resident's room; 2. Ensure infection control practices were followed per accepted standards of practice during the medication administration task by failing to: a. […]

• No harm, potential for more than minimal, widespreadF886Dec 16, 2022

  Based on observation, interview, and document review, the facility failed to implement a cohesive staff testing procedure for COVID-19 testing. Specifically, the facility failed to: 1. Ensure staff conducted Binax COVID-19 tests accurately, waiting the full 15-minute development time; and 2. Ensure results of staff self-conducted Binax COVID-19 tests were documented on the facility testing logs. Findings include: 1. The BinaxNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs. […]