Ellsworth Health Services

In the surveyor’s words

From the most serious findings on record at Ellsworth Health Services, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect all 29 residents.Facility staff did not keep personal clothing from touching food when serving residents.Facility's dishwasher records indicate dishwasher is not consistently reaching required temperatures to ensure adequate sanitization.Facility is not maintaining a sanitary environment for clean dishware.This is evidenced by:The facility's policy titled, Ware washing, dated 12/2024, states in part, 2. All dish machine water temperatures will be maintained in accordance with the manufacture's recommendations for high temperature or low temperature machines. 3. […]

• No harm, potential for more than minimal, widespreadF812May 24, 2023

  Based on observation and interviews, the facility did not prepare and distribute food under sanitary conditions. This has the potential to affect 27 of 27 residents. -Staff were not properly hand washing -Staff were using contaminated gloves -Cleaning schedule not being completed On 05/23/23 at 11:13 AM, Surveyor observed Dietary Manager (DM) G wet hands, put soap on hands and rub hands together for 3 seconds, DM G then shut off water faucet with wet hands and then dried hands with paper towels. Surveyor observed DM G empty the garbage and take it outside. […]

• No harm, potential for more than minimal, widespreadF880Mar 31, 2021

  Based on observations, interviews, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent or contain the development and transmission of communicable diseases such as COVID 19, which had the potential to affect 23 of 23 residents. Staff did not follow proper hand hygiene procedures during wound care procedure. This occurred for one of one wound care observations, resident (R) 273. Facility staff did not wear properly positioned facemasks for 3 of 3 days which had the potential to affect 23 of 23 residents. Staff did not don appropriate PPE for 1 of 2 residents on transmission based precautions, R19. […]

• No harm, potential for more than minimal, patternF812May 4, 2022

  Based on observation, interview and record review, the facility failed to store and distribute food under sanitary conditions on two of three days of survey. Frozen foods were observed to be stored in packaging that was not intact or labeled with the date they were opened or package contents. Staff was observed to touch ready to eat foods with contaminated gloves. This is evidenced by: The facility policy, entitled Food Storage, dated effective April 2020, states in part: Foods will be stored and handled to maintain the integrity of the packaging until ready for use. All foods should be covered, labeled and dated. The facility policy, entitled Bare Hand contact with food and use of Plastic Gloves, dated effective May 2020, states in part: Gloves are just like hands. They get soiled. […]

• No harm, potential for more than minimal, isolatedF689Aug 28, 2025

  Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R) 21 reviewed.This is evidenced by: Facility's policy titled Fall Prevention and Management Guideline revised date 07/18/24, read in part. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. R21 was admitted to the facility on [DATE]. R21's current diagnoses include hemiplegia and hemiparesis following cerebral infarction (CVA) affecting right dominant side, dysphagia, and cognitive communication. […]