The Ellis Rehabilitation and Nursing Center

The Ellis Rehabilitation and Nursing Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at The Ellis Rehabilitation and Nursing Center? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About The Ellis Rehabilitation and Nursing Center

The Ellis Rehabilitation and Nursing Center is a for profit, 191-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Norwood,  Westwood, Canton, Walpole, Sharon, Dedham, Medfield, Stoughton,  Needham, Norfolk, and the other towns in and surrounding Norfolk County, Massachusetts.

The Ellis Rehabilitation and Nursing Center
135 Ellis Ave
Norwood, MA 02062

Phone: (781) 762-6880
Website: http://www.theellis.com/

CMS Star Quality Rating

The Ellis Rehabilitation and Nursing CenterThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, The Ellis Rehabilitation and Nursing Center in Norwood, Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 5 out of 5 (Much Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against The Ellis Rehabilitation and Nursing Center

The Federal Government fined The Ellis Rehabilitation and Nursing Center  $47,239 on April 4th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered The Ellis Rehabilitation and Nursing Center committed the following offenses:

Failed to tell the resident completely about his or her health status, care and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the Resident’s health care proxy was fully informed in advance, and given accurate information necessary to make health care decisions including for use of [MEDICAL CONDITION] medications prior to administration for 2 Residents (#4 and #15) in a total sample of 24 Residents.

Findings include:

1. For Resident #4, the facility failed to ensure that his/her health care proxy was provided accurate dosage information necessary to make a health care decision for the following [MEDICAL CONDITION] medications: [REDACTED]. Review of the significant change Minimum Data Set with a reference date of 3/12/17 indicated that Resident #4 had moderately impaired ability to make health care decisions, required extensive assistance from staff for all activities of daily living, took [MEDICAL CONDITION] medications and had an activated health care proxy.

The medical record was reviewed on 3/30/17. Review of the March 2017, signed physician’s orders [REDACTED].#4 was taking [MEDICATION NAME] Sprinkles 125 mg twice daily (initiated 1/17/17), and [MEDICATION NAME] 20 mg twice daily (initiated 1/24/17). Review of January through March 2017 Medication Administration Records indicated that the [MEDICATION NAME] was administered as ordered by the physician. Review of the interim physician’s orders [REDACTED].

Review of the medical record indicated a signed consent form for [MEDICATION NAME] with a dosage range of 0 – 20 mg/day (20 mg less than what Resident #4 was administered daily). Further review of the medical record indicated a signed consent form for [MEDICATION NAME] Sprinkles with a dosage range identified as 5 – 10 mg/kg (kilogram) daily at weekly intervals up to 60 mg/kg daily.

During interview with Unit Manager #1 on 3/30/17 at 2:15 P.M., she said that the dose of [MEDICATION NAME] Sprinkles is administered dependent on the Resident’s weight. The Unit Manager said the Resident was receiving [MEDICATION NAME] Sprinkles 125 mg twice a day, but was unable to say how much medication Resident #4 should receive according to the dosage range calculation identified on the consent form because the Resident was no longer being weighed due to the Resident being on hospice services.

2. For Resident #15, the facility failed to obtain informed consent for the antidepressant medication [MEDICATION NAME] from the Resident’s health care proxy prior to administration as required. Review of the most recent quarterly MDS with a reference date of 2/6/17, indicated that Resident #15 had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status, required extensive assistance from staff for all activities of daily living and too antidepressant medication daily. The medical record was reviewed on 4/3/17. Resident #15 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. Review of signed physician’s orders [REDACTED].#15 was taking [MEDICATION NAME] 30 mg daily (initiated 11/14/16).

Review of November 2016 through March 2017 Medication Administration Records indicated that Resident #15 received [MEDICATION NAME] as ordered by the physician. Further review of the medical record failed to indicate a written informed consent form for [MEDICATION NAME] and there was no evidence that the facility staff reviewed the risks and benefits of the medication with Resident #15’s health care proxy.

During interview with Unit Manager #4 on 4/3/17 at 10:20 A.M., she said that there was no written consent for the medication [MEDICATION NAME] and that she would get a consent form signed by the health care proxy.

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility Failed to ensure that Residents have the least restrictive devices for the least amount of time and failed to release and remove restraints per the plan of care for 3 of 3 sampled Residents with restraints (#2, #3, & #4), from a total of 24 sampled Residents.

Findings include:

A review of the Facility policies for Restraints and abuse, neglect, mistreatment, exploitation, and misappropriation of resident property was conducted. The policies indicated that when a restraint was in use, the Facility would use the least restrictive alternative for the least amount of time, initiate a restraint care plan and document according to physician’s orders [REDACTED].

1. For Resident #2, the Facility failed to consistently follow the plan of care to release the Resident’s seatbelt during meals and during supervised activities. Resident #2 was admitted to the Facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the Physical Restraint Elimination Assessment, dated 1/10/17 indicated that Resident #2 scored 15 indicating that he/she was a priority candidate for restraint elimination. The narrative section of the assessment indicated that the Resident remained at high risk of falls secondary to poor short term memory with associated poor safety awareness and will continue velcro belt as a safety reminder.

Review of the quarterly Minimum Data Set (MDS) assessment signed as being completed on 2/20/17 indicated that Resident #2 was cognitively impaired and used a trunk restraint daily. The clinical record was reviewed on 3/29/17. Review of the physician’s orders [REDACTED].#2 had an order for [REDACTED]. Review of the care plan for restraints, last updated on 2/2017, indicated that Resident #2 used an alarming self release Velcro seatbelt while seated in the wheelchair. It also indicated that the Resident’s restraint should be released at supervised meals, visits, and activities.

On 3/30/17 at 7:30 A.M. the Surveyor interviewed Resident #2. The Resident was unable to remove the seatbelt on command. The Resident said the seatbelt was there so he/she wouldn’t get up.

Resident #2 was observed by the surveyor on the following occasions:

– On 3/30/17 at 11:00 A.M., Resident #2 was observed seated in his/her wheelchair with the seatbelt attached, in the unit dayroom. The activity assistant was conducting an activity. The Resident’s eyes were closed and his/her head was bowed throughout the activity. The seatbelt was not released during the activity.

– On 3/31/17 at 8:45 A.M. Resident #2 was observed seated in his/her wheelchair with the seatbelt attached eating breakfast in the unit dayroom. The Unit Manager (UM #4) and a Nurse (#2) were in the dayroom assisting Residents with breakfast. The seatbelt was not released while the Resident was eating

– On 3/31/17 at 10:30 A.M. Resident #2 was observed seated in his/her wheelchair with the seatbelt attached, in the unit dayroom. The activity assistant was conducting an activity. The Resident’s eyes were closed and his/her head was bowed throughout the activity. The seatbelt was not released during the activity.

– On 4/4/17 at 10:15 A.M. Resident #2 was observed seated in his/her wheelchair with the seatbelt attached, in the unit dayroom. The activity assistant was conducting an activity.

The seatbelt was not released during the activity. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 11:30 A.M. on 4/4/17. The ADON said staff should be releasing the belt during meals and during supervised activities.

2. For Resident #3 the Facility staff failed to consistently follow the plan of care to release the Resident’s clip seatbelt as indicated in the physician’s orders [REDACTED]. Resident #3 was admitted to the Facility in 06/2012 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment signed as complete on 12/19/16 indicated that Resident #3 was cognitively impaired with a score of 03 out of 15 on the Brief Interview of Mental Status and used a trunk restraint daily.

A review of the physician’s orders [REDACTED].#3 had an order for [REDACTED]. Review of the Physical Restraint Elimination Assessment, dated 03/13/17 indicated that Resident #3 scored 21 indicating that he/she was a good candidate for restraint elimination. The narrative section of the assessment indicated that the Resident had remained safe and continued with a clip seatbelt.

Review of the care plan for restraints, last updated on 03/20/17, indicated that Resident #3 used a clip seatbelt while seated in the wheelchair. It also indicated that the Resident’s restraint should be released at supervised meals, visits, activities, ambulation and toileting.

Resident #3 was observed on the following days:

On 03/29/17 at 3:20 PM. the Resident was in the unit dining room watching a movie, a staff member was present. The Resident was not attempting to leave the room or get out of the wheel chair. The seatbelt remained intact at this time.

On 03/30/17 at 8:05 A.M. the Resident was observed in the unit dining room having breakfast. The Resident was seated at a table and was feeding him/herself. The Resident was not attempting to leave the room or stand. The seatbelt remained intact at this time.

On 03/31/17 from 12:00 P.M. until 12:35 P.M. the Resident was observed in the main dining area (solarium) for lunch. The Resident was seated at a table with other Resident’s. The Resident was not attempting to leave the room or stand. The seatbelt remained intact at this time.

An interview was conducted with Unit Manager #2 on 03/31/17 at 10:30 A.M. Unit Manager #2 said the Resident had utilized a clip seatbelt since 06/2016. Unit Manager #2 said Resident #3 had sporadically released the seatbelt and that there was no set schedule to release the seatbelt. Unit Manager #2 confirmed that the seatbelt had not been released during meals. Unit Manager #2 was unaware of the order to release the restraint during meals and activities with supervision. Unit Manager #2 said the nurses signed off on the Treatment Administration Record (TAR) once per shift for the seatbelt order and that there was not a place to document for release during meals and activities.

3. For Resident #4, the Facility staff failed to consistently follow the plan of care to release the Resident’s breakaway alarm lap cushion as indicated in the physician’s orders [REDACTED]. Resident #5 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the significant change MDS with a reference date of 3/12/17 indicated that Resident #4 had moderate impaired ability to make health care decisions, required

extensive assistance from staff for all activities of daily living and had a restraint. The medical record was reviewed on 3/30/17. Review of the Pre-Restraining assessment dated [DATE], indicated a breakaway alarm lap cushion was indicated for the Resident’s poor safety awareness and to improve positioning while he/she was out of bed in a wheelchair.

Review of the medical record indicated a physician’s orders [REDACTED]. Review of the interdisciplinary care plan for restraints, indicated a breakaway alarmed lap cushion was being utilized while the Resident was out of bed in a wheelchair due to the him/her wandering without regard for personal/others safety, poor insight/judgement, and tendency for impulsive behaviors and history of falls. Further review of the restraint care plan indicated that the restraint would be released every 2 hours and as needed (PRN), released during supervised meals, activities, and while under direct supervision.

Review of January, February, and March 2017 Treatment Administration Records failed to indicate that the restraint was released according to physician’s orders [REDACTED]. The Resident was observed on the following occasions:

3/29/17 at approximately 9:30 A.M. during initial tour of the unit, Resident #4 was observed seated in a wheelchair in the unit dayroom with the breakaway alarmed lap cushion in place while under direct supervision of staff.

3/30/17 at 10:00 A.M., Resident #4 was observed seated in a wheelchair in the unit dayroom with the breakaway alarmed lap cushion in place while in an activity (watching a religious service on the television) and under direct supervision of staff.

3/30/17 11:50 A.M. to 12:10 P.M., Resident #4 was observed in the unit dayroom seated in a wheelchair at a dining table with the breakaway alarmed lap cushion secured in place while being assisted to eat by a certified nursing assistant (CNA). The lap cushion prevented the Resident from setting close enough to the table to reach his/her beverage without assistance. A clothing protector was in place on the front of the Resident’s shirt and another cloth was draped over the lap cushion and appeared to be like a tablecloth. However, the lap cushion’s fastener was clearly visible and in the locked position during the observation.

During interview with Unit manager #1 on 3/30/17 at 2:15 P.M., she said that staff do not document the release of the alarmed lap cushion every 2 hours, during meals, activities, and while under direct supervision by staff because it is not a restraint and does not need to be released.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the Facility staff failed to follow their policies and procedures regarding an abuse allegation for 1 sampled resident (#5) from a total sample of 24 Residents. The Facility failed to check the Nurse Aid Registry prior to hire; and for 2 out of 5 newly hired employees

Findings include:

A review of the Facility policy and procedures regarding abuse, neglect, mistreatment, exploitation, and misappropriation of resident property was conducted. The policy indicated the following:

– the Facility would immediately begin to investigate all allegations of abuse of a resident
– the investigation would include interviewing all witnesses and obtaining written statements -steps would be initiated to prevent further abuse
-the investigation would be reported to the Administrator

The facility staff failed to follow their policy to fully investigate and report an allegation of abuse for Resident #5. Resident #5 was admitted in 06/2016 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], indicated Resident #5 scored a 6 out of 15 on the Brief Interview of Mental Status, indicating the Resident had a severely impaired cognition.

A record review conducted on 03/30/17 indicated Resident #5 was seen by the physician on 12/6/16. The physician documented that the Resident had told physical therapy that one of the staff members was physically aggressive with him/her. Further record review of nursing notes and social service notes did not mention an allegation of abuse or an investigation. On 03/30/17 at 11:00 A.M. the surveyor requested the investigation in to the allegation of abuse from 12/2016 from the Director of Nursing (DON).

On 03/30/17 at 4:00 P.M. the Clinical Consultant was interviewed. The Clinical Consultant said the allegation was not investigated because the administrative staff were unaware of the allegation. She said the DON called the physician on this day and the physician was going to write an addendum to her note that the Resident was not abused. The Clinical Consultant said the Unit Manager (#2) and physician discussed the allegation on 12/6/16 and determined Resident #5 was confused related to his/her medical diagnosis.

On 03/31/17 at 9:45 A.M. Unit Manager #2 was interviewed. Unit Manager #2 said she recalled the allegation of abuse from 12/6/16. Unit Manager #2 was told by the physician of an allegation of abuse from Resident #5. She said she went to Resident #5 in the unit dining room (where there were other Residents) and asked a question to the effect of how are things going? The Resident did not mention the allegation. She said due to the Residents increased confusion she did not feel that the allegation would need to be investigated. She confirmed that none of the staff, including the physical therapist who reported the allegation, were interviewed. Unit Manager #2 was unable to recall if the allegation had been reported to the DON or the Administrator. She said she was aware that all allegations of abuse need to be investigated, even if the Resident was confused.

2. The Facility failed to check the Nurse Aid Registry prior to hire; and for 2 out of 5 newly hired employees

a. For Employee #2, who was hired on 12/5/16, the Facility failed to check his/her Certified Nurse Aid Registry prior to hire. The check was not done until 4/3/17.

b. For Employee #6, was hired on 2/6/17 and a review of the personnel file indicated that Nurse Aid Registry checks were not completed in Massachusetts prior to hire. During an interview on 4/3/17 at 2:15 P.M., the Director of Nurses was notified and was unable to to provide verification that the Nurse Aid Registry checks had been completed.

Failed to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the Facility staff failed to ensure that for 2 Residents (#1 and #16), of a total sample of 24 Residents, that care and services were provided to prevent the development of deep tissue pressure injuries.

Findings include:

A review of the Facility policy for Pressure Ulcers/ Skin Breakdown- Clinical Protocol was conducted. The assessment and recognition section indicated the nurse shall describe and document a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue and the physician will help the staff review and modify the care plan as appropriate.

1. For Resident #1 the Facility staff failed to ensure a pressure relieving device was in place to prevent the development of a deep tissue pressure injury on the coccyx per the facility policy.

Resident #1 was admitted in 08/2011 with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), signed as being completed 01/09/17, the Resident was severely cognitively impaired. The MDS indicated that the Resident required assistance with bed mobility, transfers, ambulation, and dressing. The MDS also indicated that the Resident was at risk for pressure ulcers.

During a tour of the unit on 03/29/17 at 9:30 A.M. the Unit Manager (#2) said Resident #1 had a healed pressure area on the coccyx and was unsure if the Resident had any open areas on their heels. The Resident was observed to have an air mattress on the bed. Review of the medical record was conducted on 03/29/17. A nursing note dated 03/28/17 at 12:30 P.M. indicated Resident #1 had a new open area to the left buttocks, with no drainage and a new order was implemented for normal saline wash, pat dry and apply calcium alginate and cover with a foam dressing.

The Norton Plus Pressure Ulcer Risk assessment dated [DATE] was reviewed. The Norton Assessment coded the Resident as a 9 and at High Risk for pressure injury. Risk factors listed on the Norton Assessment included the following:

– Physical Condition-poor
– Mental State- confused
– Mobility-very limited
-Incontinence-double incontinence

The Care Plan for Skin Breakdown (Potential) initiated on 01/11/17 indicated a potential for skin breakdown related to impaired mobility and incontinence of bowel and bladder with a goal of reducing the potential for skin breakdown for 90 days. The approaches listed to obtain the goal included:

-weekly skin check
-norton assessments quarterly and as needed
-barrier cream
-pressure relieving mattress and /or cushion for wheelchair daily

A review of the nutritional status for Resident #1 included a quarterly review from the Registered Dietitian written on 03/28/17. The Dietician noted that the Resident had weight loss over three months and his/her weight had stabilized for the previous two weeks. Review of the interim notes from the Dietician indicated the Resident had a weight of 112 lbs (pounds) during the week of 02/25/17 and a weight of 111 lbs the week of 03/28/17, indicating a stable weight for one month.

On 03/29/17 at 12:40 P.M. Resident #1 was observed in the unit dining room to be sitting in a maroon wheelchair with foot rests and he/she was not sitting on a pressure relieving device (cushion). The Resident was observed again at 4:30 P.M. to be in the unit dining room, sitting in the wheelchair without a cushion.

An interview with Unit Manager #2 was conducted on 03/29/17 at 4:10 P.M. The Unit Manager said the open area was found on 03/28/17 and would be assessed by the wound physician from Vohra the following day. She said the new open area was not an area that had recently healed. The Unit Manager said there were currently no measurements available for the wound as the nurse did not complete them per facility policy.

The Nurse (#1) on the unit, who had written the note identifying the wound, was interviewed on 03/30/17 at 3:00 P.M. She said she was alerted by a Certified Nursing Assistant (CNA) of the wound. She said she had not taken measurements of the wound as the Unit Manager usually measures the wound and that she had notified Unit Manager #2 of the wound when it was identified on 03/28/17.

The wound physician was interviewed on 03/30/17 at 8:00 A.M. He said he had seen Resident #1 that morning and the wound, located on the coccyx, was unstagable prior to his treatment and would be a stage III following his debridement. He said the open area was slightly to the right of the previous open area, which healed a couple of weeks prior. The wound physician said the he was surprised the Resident had another breakdown in skin so fast. The Surveyor inquired about a pressure relieving device in the wheelchair and the wound physician said if a cushion had been used in the wheelchair it absolutely would have helped to prevent the pressure area.

A review of the evaluation from the wound physician, dated 03/30/17 indicated there was an unstageable (due to necrosis) area on the coccyx of at least 4 days duration with light serous exudate. The wound measured 2.5 x 1.5 x 0.2 cm (centimeters).

Unit Manager #2 was interviewed on 03/31/17 at 10:30 A.M. The Unit Manager stated the Resident previously had a cushion for her wheelchair and it was part of the plan of care for Resident #1. The Unit Manager stated the CNAs were concerned about the roommate of Resident #1 and had provided the cushion for Resident #1 to the roommate.

2. For Resident #16 the Facility staff failed to ensure a pressure relieving device was utilized to promote the healing of pressure ulcers to the left and right heels. Resident #16 was admitted in 03/2010 with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), signed as being completed 02/06/17, the Resident was severely cognitively impaired. The MDS indicated that the Resident required assistance with bed mobility, transfers, ambulation, and dressing. The MDS also indicated that the Resident was at risk for pressure ulcers.

During a tour of the unit on 03/29/17 at 9:30 A.M. the Unit Manager (#2) said Resident #16 had pressure areas to the bilateral heels. Resident #16 was observed to be in bed, a pump for the air mattress was observed to be on the mattress at the foot of the bed and the left foot of Resident #16 was up against the pump. It was observed that both of the Resident’s heels were resting on the mattress.

Review of the medical record was conducted on 03/31/17. A nursing note dated 03/13/17 indicated the left and right heels for Resident #16 were breaking down. The note indicated the left heel area was measuring 1.3 x 2.4 cm.

The Norton Plus Pressure Ulcer Risk assessment dated [DATE] was reviewed. The Norton Assessment coded the Resident as an 8 and at High Risk for pressure injury. Risk factors listed on the Norton Assessment included the following:

– Physical Condition-poor
– Mental State- confused
– Activity- chair bound
– Mobility-very limited
-Incontinence-double incontinence

A review of the physician progress notes [REDACTED].#16 indicated the Resident was in a vegetative state, continuously bed bound and appeared fairly hydrated and nourished. A review of the evaluation from the wound physician, dated 03/16/17 indicated there was a stage III pressure wound to the left heel (3 x 2 x 0.2 cm) of at least 5 days duration with light serous exudate. The recommendation was to off-load the wound, reposition per facility protocol and float heels in bed.

On 03/31/17 at 11:30 A.M. Resident #16 was observed in bed, a pump for the air mattress was observed to be on the mattress at the foot of the bed, an off loading device was observed under the Resident’s knees and both heels were observed to be on the mattress. The Resident was observed again at 2:00 P.M. with Unit Manager #2. The Resident was in bed, with the mattress pump on the mattress and the off loading device was placed under the Resident’s knees, which placed the Resident’s heels on the mattress. Unit Manager #2 said that the off loading device should not be that high up under the legs and that the device was used to float the heels of Resident #16 off of the mattress.

Failed to store, cook, and serve food in a safe and clean way

Based on observation and staff interviews, the facility failed to follow proper sanitation and food storage practices to prevent the outbreak of food borne illness.

Findings include:

On 3/31/17 at 10:30 A.M. and on 4/3/17 at 9:45 A.M., observations for sanitation of 3 nourishment kitchens was conducted. The following food sanitation issues were observed::

1. Cherrywood – On 3/31/17 at 10:30 A.M., observation of the Cherrywood nourishment kitchen included the following improper storage of foods and improper sanitation. – the ice machine door inside and outside was dirty. There were colored liquids spilled on the inside of the door and the gasket had a black film in the crevice, as well as on the outer part of the ice machine’s seal.

2. Driftwood – On 4/3/17 at 11:00 A.M., the Driftwood nourishment kitchen observations included:

-the ice machine’s gasket was sticky and had black and brown film in the crevices
-under the kitchen sink there were 6 dusty flower vases and empty soda bottles
-the refrigerator contained multiple food products that were not dated, had expired and were open that included 2 thickened dairy products that had expired on 3/31/17 and 3/17/17; a bottle of water, a Styrofoam cup that was half filled with an unidentified liquid, 2 bottles of ice tea, an apple and orange in a plastic bag, 1 container of Ensure, 2 packets of watermelon chunks.
-the freezer had half gallon of sherbet, 2 frozen water bottles and the freezer had an orange and brown film that was sticky. 3.
Applewood

– Observations on 4/3/17 at 12:50 P.M. included:
-under the kitchen sink, staff had stored paper towels, a pink basin and coffee mugs
-the ice machine had a yellowish tinged on the door and the crevices of the seal was dirty and there was a black and brown film on the gasket
-the freezer had 1 quart of ice cream that the lid was not secured and a second container that was opened, neither container was dated and labeled.
-the freezer door was dirty and the shelf had a pink sticky substance on the shelf, with a clear plastic tumbler filled with frozen water on the shelf
-the refrigerator had 12 bottles of drinks that were opened and not dated. The containers had caps that were not secured (orange juice, prune juice, cranberry juice etc),
-the refrigerator had a pink substance splashed on the inside of the door and the gasket had crumbs and a brown sticky substance along the edges During the tour on 4/3/17 at 12:50 P.M., the Dietician said that the kitchen staff stocked the kitchen areas and that that housekeeping and all staff were responsible for sanitation.

Failed to make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of pest control reports, facility policy and interviews with staff and the pest control service, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests, that included bed bugs.

Findings include:

Prior to the surveyor, 2 reports had been filed with the Department of Public Health (12/12/16 and 12/13/16) that alleged that the Facility failed to address an infestation of bed bugs. The Department requested that the issue be followed up during the survey process.

On 4/3/17 at 9:30 A.M., the Surveyor requested the Facility’s pest control report and policy/procedure for bed bugs. The Maintenance Director said that bed bugs were found in the facility on the Driftwood Unit, and that the Housekeeping Director would provide the report and information.

Following the request, the Surveyor made 2 additional requests for the Facility’s documentation to determine if the facility had implemented an effective pest control program so that the Facility could ensure they were free of bed bugs.

At 10:45 A.M. on 4/3/17, the Surveyor requested the documents from the Director of Nurses and at 11/30 A.M. went to the Housekeeping office to obtain the file on the bed bugs. The Director of Housekeeping was observed writing and said that he was getting everything together. The Surveyor asked if he was writing the report and he said Yes I’m writing it up now. The Director provided 2 pest control reports dated 12/9/16 and 12/11/16.

Review of the pest reports indicated that on 12/9/16, the Facility called to treat for bed bugs in 1 room. The report indicated that the room had not been properly prepared and that there were sheets still on the bed and the bags with personal items and clothes were not sealed tightly. The provider indicated that he/she bagged the sheets and found bed bugs on the mattress and curtains. The report did not indicate the Pest Control provided checked any other rooms or the second bed in the room.

Review of the 12/12/16 report indicated he/she inspected 4 rooms (including the original room) on the Driftwood Unit for bed bugs and found bed bugs in a second room. The Pest Control company treated all furniture, closets, perimeter and electric outlets. There was was no information to support that the Facility cleaned the room after the treatment by pest control.

There was no subsequent reinspection reports. On 4/3/17 at 12:00 P.M., the Housekeeping Director provided a file folder. The folder was identified as the Bed Bug Treatment Procedure. The Housekeeping Director said that the staff had found bed bugs on an air mattress of a long term care Resident on the Driftwood Unit. He could not remember the room or the Resident name. He said the Facility had contacted the Pest Control provider to treat for the bed bugs. He said once the Pest Control treated the area the staff would subsequently the room. The Director said that staff would then bag all the Resident’s belongings and that the entire room was checked for bed bugs. The Director was not clear if the roommates belongings were bagged and/or required treatment for [REDACTED].

The Director of Housekeeping said that the facility had not checked any other rooms prior to calling the Pest Control company, because the Pest Control company usually looks at a 4 room radius when treating for pest. He said following the initial treatment, the Pest Control company had found another room with bed bugs. The Director said the room was on the other end of the corridor and it was not clear how the bed bugs got there. He said that his staff had not followed up and left the the reinspection to the Pest Control company.

Review of the two pest management procedures indicated that specific steps were required to rid the facility of bed bugs, that included inspection of the area, storing and sanitizing (with heat and chemicals) clothing, shoes, toys, pillows and bedding, vacuuming of all areas and crevices, making sure the handling of a bed bug vacuum is systematic to avoid transferring the bed bugs to new location, washing surfaces (with soaps and steam, not bleach and ammonia), including furniture, floors, mattresses, molding, window sills etc.

The Facility’s policy indicated they call pest control, shower the Resident, bag all personal items and have them treated by the Pest Control Provider, clothing will be bagged and sent to laundry for washing, discard mattress and pillows, close room for treatment and wait 6 hours after Pest Control treats, clean all furniture with Clorox germicidal wipes, and pest control to reinspect on next weekly visit. There was no mention of vacuuming and/or how the materials used to clean and the mattress would to be discarded. The Manger from the Pest Control provider was interviewed on 4/3/17 at 12:45 P.M. He said that the Facility was to prepare the room prior to treatment. He said it was the expectation that the Resident’s personal items, clothing and furniture, linens and room was cleaned thoroughly and clothing and other items bagged. He said once the pest were identified and then treated that they would reapply the pesticide and have a reinspection. Other than the second report there was no evidence this was done, however, the Manager said he would, but none were provided.

On 4/3/17 at 1:15 P.M., Unit Manager #4 was asked about bed bug infestation and she said it happened before she had started working at the Facility.

The Ellis Rehabilitation and Nursing Center, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – The Ellis Rehabilitation and Nursing Center

Inspection Report for The Ellis Rehabilitation and Nursing Center– 04/04/2017

Page Last Updated: April 23, 2018

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