Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ellsworth Health Services during CMS and state inspections, most recent first.
Unsafe Food Handling and Dishwashing Sanitation: Surveyors observed dietary staff touching plated food with a t-shirt while serving, and another manager preparing food after washing dirty dishes without an apron, with splashed water and debris on clothing. Dishwasher logs showed multiple temperatures below the facility’s required ranges, backup monitoring was not documented, and an uncovered bin of cloudy dirty water was observed on the floor in the clean dish area.
A resident with CVA-related right-sided weakness, moderate cognitive impairment, and dependence for transfers and toileting was identified as a fall risk with interventions including a low bed and fall mat. Surveyors observed the resident in bed with the bed in low position but no fall mat on the floor next to the bed; a CNA confirmed the mat was missing and then placed it, and the DON verified the mat should have been in place.
A resident with CHF experienced significant weight gain and worsening symptoms over several months, but the facility failed to conduct comprehensive cardiovascular and respiratory assessments. Despite monitoring weight and symptoms, the facility relied on exception-based documentation, leading to a lack of timely intervention. The resident was eventually hospitalized for acute on chronic diastolic CHF, highlighting deficiencies in ongoing assessment and care.
Unsafe Food Handling and Dishwashing Sanitation
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation and distribution. On 08/26/25, a surveyor observed a dietary staff member dish up food to plates on the edge of the steam table while leaning forward so that the staff member’s t-shirt touched residents’ food and plates. The District Dietary Manager also observed the shirt touching the plated food and stated that staff were expected to wear aprons to prevent cross-contamination. The surveyor also observed the Dietary Manager prepare an alternative food item after washing dirty dishes in the dirty dishwashing area without wearing an apron, with visible splashed water and debris on the manager’s clothing when returning to the cooking/serving area to make a sandwich for a resident. The surveyor reviewed the dishwasher temperature log and found several entries below the facility’s stated high-temperature wash range of 150-165 degrees F and rinse range of 180-194 degrees F. The Dietary Manager stated she was unaware of the below-standard temperatures and that they should have been reported per the log instructions. The surveyor also observed the manager remove a dirty recycle bin from in front of the dishwasher to read the digital thermometer, and the manager stated that backup monitoring of dishwashing temperatures was not being documented. In addition, the surveyor observed an uncovered plastic bin containing cloudy, dirty water on the floor directly under the dishwasher; the manager did not know why it was there and agreed it should not have been in that area. The District Dietary Manager agreed that staff should wear a designated apron for dishes and that the recycle bin and open dirty tote of water should not have been in the clean dish area. The Dietary Manager later stated the facility was working on getting guidelines in place and did not have specific direction available.
Missing Fall Mat for Resident at Risk for Falls
Penalty
Summary
The facility did not ensure that a resident with significant functional and cognitive impairment received the ordered fall-prevention interventions while in bed. The resident had diagnoses including hemiplegia and hemiparesis following a CVA affecting the right dominant side, dysphagia, and cognitive communication impairment. The resident’s MDS documented a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and the resident was dependent on staff for toileting, lower body dressing, personal hygiene, bed mobility, and transfers. The care plan identified the resident as at risk for falls related to right-sided weakness, a flaccid right hand, inability to ambulate, and use of a wheelchair with total assist. The care plan interventions included placing the bed in the lowest position at bedtime or when in bed and using a fall mat. During observation, the resident was found in bed with the bed in the low position, but the fall mat was not on the floor next to the bed. A CNA stated the fall mat should be in place and that she had not placed the resident in bed that morning. After being asked to verify the interventions, the CNA entered the room, confirmed the fall mat was not on the floor, and then placed it next to the bed. The DON later verified that the fall mat should have been in place.
Failure to Conduct Comprehensive Assessments for CHF
Penalty
Summary
The facility failed to ensure that a resident with congestive heart failure (CHF) received treatment and care in accordance with professional standards of practice. The resident, who had a history of CHF, hypertensive heart disease, mitral valve stenosis, pulmonary hypertension, and chronic kidney disease, experienced a significant weight gain and worsening symptoms over several months. Despite these changes, the facility did not conduct comprehensive cardiovascular and respiratory assessments, such as auscultating lung and heart sounds or assessing jugular venous distention, which are critical for monitoring CHF. The resident's care plan included monitoring for symptoms of CHF, such as edema and shortness of breath, but the facility's documentation was incomplete. Nurses documented the presence of shortness of breath and edema but did not perform or record detailed cardiovascular examinations. The facility relied on exception-based documentation, meaning assessments were only recorded if concerns were noted, which led to a lack of regular, thorough assessments. This approach contributed to the resident's condition worsening without timely intervention. Interviews with staff revealed that while the resident's weight and symptoms were monitored, there was a lack of urgency in addressing the gradual weight gain and worsening symptoms. The facility's primary provider was aware of the resident's condition but chose to wait for a cardiology appointment to adjust medications, given the resident's kidney function. Ultimately, the resident was hospitalized for acute on chronic diastolic CHF after a cardiology appointment, highlighting the deficiency in ongoing assessment and timely intervention by the facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ellsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kinnic Health And Rehabilitation Center | 10.4 mi | ★★★★★ | 0 | 0 |
| Spring Valley Health And Rehab Center | 12.5 mi | ★★★★★ | 13 | 0 |
| St Crispin Living Community | 14.2 mi | ★★★★★ | 15 | 1 |
| Prescott Nursing And Rehab Community | 14.7 mi | ★★★★★ | 6 | 0 |
| Baldwin Care Center | 16.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.