Every finding on record at Willis-Knighton Extended Care Center

Based on record reviews and interviews the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to accurately monitor the refrigerator and freezer temperatures and failed to accurately maintain the dishwasher machine temperature. This had the potential to affect 18 residents who were served trays out of the kitchen according to the Dietary Manager. Findings: Review of the facility's refrigerator and freezer temperature logs revealed temperatures were documented with no variations from 11/01/2024 to 03/11/2025. The refrigerator temperature logs were listed as follows: the internal manual thermometer temperature was 36 degrees F (Fahrenheit), the internal electric thermometer temperature was 40 degrees F, and the external thermometer temperature was 41 degrees F. The freezer temperature logs were listed as follows: the internal manual thermometer temperature was 10 degrees F, the internal electric thermometer temperature was 10 degrees F, and external thermometer temperature was 10 degrees F. Review of the facility's dish machine temperature strip logs from 11/01/2024 to 03/11/2025 revealed the test strip reading as 100 degrees F daily with no deviations. Observation on 03/11/2025 at 8:00 a.m. with S2 Dietary Supervisor revealed S2 Dietary Supervisor was unable to find the manual internal thermometer for the refrigerator and the internal digital thermometer was in Celsius for the refrigerator and freezer. During an interview on 03/11/2025 at 8:00 a.m. S2 Dietary Supervisor reported I'm not gonna lie, the refrigerator and freezer temperatures were fine yesterday so I just used the same temps from yesterday and wrote them down. S2 Dietary Supervisor further reported she wasn't sure exactly where the temperatures recorded on the log came from and reported she could not work the digital thermometers and did not know how to read Celsius. During an interview on 03/11/2025 at 8:20 a.m. S3 Assistant Dietary Manager reported The dishwasher company turned the dish machine temperature down to 100 degrees F because we couldn't get an accurate reading about a year ago. During an interview on 03/11/2025 at 4:30 p.m. S1 Administrator reported are going to have to add a temperature booster to get the water up to where it should be at least 120 degrees Fahrenheit.

Based on record review and interviews, the facility failed to implement the care plan for 1 (#1) out of 3 (#1, #2, #3) residents reviewed for falls. The facility failed to use a gait belt for Resident #1 during ambulation. Findings: Review of Facility's Clinical Protocol for Falls (undated) revealed: Purpose: It is the policy of ___Care that the facility shall identify patients at risk for falling and take steps to prevent future fall occurrences. Review of Resident #1's medical records revealed an admitted [DATE] with the following diagnoses, in part but not limited to: femoral neck fracture, neuropathy, recurrent falls, and left knee DJD (degenerative joint disease). Review of Resident #1's Baseline Care Plan revealed summary concerns of a fall risk and gait belt use. Review of Resident #1's ___Fall Risk Assessment Scale dated 12/18/2024 revealed a total score of 23 indicating a high fall risk (15 or >). Further review of ___Rehab Fall Risk Care Plan revealed: mobility, in part: . gait belt when assisting patient to ambulate. During a telephone interview on 02/06/2025 at 8:05 a.m. S1 CNA (Certified Nurse Assistant) confirmed Resident #1 required a gait belt with ambulation. S1 CNA acknowledged on 01/17/2025 she ambulated Resident #1 without using a gait belt. During an interview on 02/06/2025 at 10:48 a.m. S1 ADON (Assistant Director of Nursing) reported the staff are to use a gait belt when assisting residents to ambulate. S1 ADON acknowledged Resident #1 was ambulated without a gait belt and should not have been.

Based on record reviews and interviews, the facility failed to ensure the medical record reflected an advance directive for 5 residents (#92, #93, #141, #144, #145) out of 16 reviewed for advance directives. The facility's census was 16 as documented on the facility's Resident Census and Conditions of Residents form dated 4/25/2022. Findings: Review of Advance Directives policy (Revised December 2006) revealed: Policy Statement Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation . 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Should the resident indicate that he or she has issued advance directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record. . 9. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. . -Resident #92 Review of Resident #92's medical record revealed an admitted [DATE]. Review of Resident #92's EHR (Electronic Health Record) revealed Code Status Not Ordered and no history available. Review of Resident #92's paper chart failed to reveal Resident #92's code status. During an interview on 4/26/22 at 10:00 AM S1 RN (Registered Nurse) reviewed Resident #92's medical record and acknowledged code status in EHR was documented as Code status not ordered and no history available. S1 RN reviewed paper medical records and acknowledged there was not documentation regarding code status. -Resident #93 Review of Resident #93's medical record revealed an admitted [DATE]. Review of Resident #93's EHR revealed Code Status Not Ordered with history available. Review of the history available revealed Resident #93 had code status of Do Not Resuscitate (DNR) with a start date of 4/8/2022 prior to facility entry. Review of Resident #93's paper chart failed to reveal Resident #93's code status. During an interview on 4/26/22 at 10:00 AM S1 RN reviewed Resident #93's medical record and acknowledged code status in EHR was documented as Code status not ordered with history available that indicated prior DNR code status. S1 RN reviewed paper medical records and acknowledged there was not documentation regarding code status. S1 RN further reported if there was not a code status ordered then the resident is considered a full code. During an interview on 4/26/2022 at 10:05 AM S2 RN reported she had just spoken with Resident #93 and Resident #93 reported if her heart stopped, she did not want to be resuscitated. -Resident #141 Review of Resident #141's medical record revealed an admitted [DATE]. Review of Resident #141's EHR revealed Code Status Not Ordered and no history available. Review of Resident #141's paper chart failed to reveal Resident #141's code status. During an interview on 4/26/22 at 10:00 AM S1 RN reviewed Resident #141's medical record and acknowledged code status in EHR was documented as Code status not ordered and no history available. S1 RN reviewed Resident #141's paper medical records and acknowledged there was not documentation regarding Resident #141's code status. -Resident #144 Review of Resident #144's medical record revealed an admitted [DATE]. Review of Resident #144's EHR revealed Code Status Not Ordered and no history available. Review of Resident #144's paper chart failed to reveal Resident #144's code status. During an interview on 4/26/22 at 10:00 AM S1 RN reviewed Resident #144's medical record and acknowledged code status in EHR was documented as Code status not ordered and no history available. S1 RN reviewed Resident #144's paper medical records and acknowledged there was not documentation regarding Resident #144's code status. -Resident #145 Review of Resident #145's medical record revealed an admitted [DATE]. Review of Resident #145's EHR revealed Code Status Not Ordered and no history available. Review of Resident #145's paper chart failed to reveal Resident #145's code status. During an interview on 4/26/22 at 10:00 AM S1 RN reviewed Resident #145's medical record and acknowledged code status in EHR was documented as Code status not ordered and no history available. S1 RN reviewed Resident #145's paper medical records and acknowledged there was not documentation regarding Resident #145's code status.

Based on observations and interviews the facility failed to ensure food was served in accordance with professional standards for food service safety for the 15 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure steam table and portable hot box temperature monitoring was conducted with each meal service. The facility's census was 16 as documented on the facility's Resident Census and Condition of Residents form dated 4/25/22. Findings: Review of the facility's steam table temperature monitoring logs for April 2022 revealed the following: -Breakfast temperatures were only documented on 4/1/22, 4/2/22, 4/5/22, 4/6/22, 4/18/22, and 4/19/22. -Lunch temperatures were only documented on 4/2/22 and 4/3/22. -Dinner temperatures were only documented on 4/1/22, 4/2/22, and 4/3/22. Review of the facility's portable hot box temperature monitoring logs for April 2022 revealed the following: -Breakfast temperatures were only documented on 4/2/22, 4/3/22, and 4/5/22. -Lunch temperatures were only documented on 4/2/22, 4/3/22, and 4/5/22. -Dinner temperatures were only documented on 4/1/22 and 4/2/22. During an interview on 4/25/22 at 11:52 AM S3 Dietary Supervisor reported food was prepared at the adjacent hospital kitchen and transported to the facility's kitchen for service to the residents. S3 Dietary manager reported the food was placed on the steam tables for service and steam table temperatures were monitored with each meal service. S3 Dietary Manager reviewed the facility's April 2022 steam table monitoring logs and acknowledged there were temperatures not documented for breakfast, lunch and dinner meals and should have been. During an interview on 4/25/22 at 11:50 AM S4 Dietary Manager reported the food was taken from the steam line after service and held in the portable hotbox for 2 hours after service then discarded. S4 Dietary Manager reported the portable hotbox ensures food is kept warm until time to discard and prepare for the next food service. S4 Dietary Manager reviewed the facility's April 2022 portable hot box temperature logs and acknowledged temperatures were not documented for breakfast, lunch, and dinner meals and should have been. S4 Dietary Manager further reviewed the facility's April 2022 steam table monitoring logs and acknowledged there were temperatures not documented for breakfast, lunch and dinner meals and should have been.

Based on observations and interview the facility failed to ensure proper infection control practices were followed to prevent the spread of infection for 1 (#56) of 1 (#56) resident observed for perineum care out of a total sample of 12 residents. Findings: Observation on 6/5/19 at 11:00 am revealed resident #56 was assisted by S1 CNA (certified nursing assistant) with toileting. Resident #56 was seated on the toilet and S1 CNA was wearing gloves and using wet wipes to clean a bowel movement from resident #56. S1 CNA wore the same gloves to help resident #56 pull up her pants, used resident #56's gait belt to assist resident #56 to a bedside chair, placed a pillow behind resident #56's head, and pulled a blanket up around resident #56's body. S1 CNA then removed and discarded the gloves and washed her hands at the sink in resident #56's room. During an interview on 6/5/19 at 11:20 am S1 CNA acknowledged she did not change gloves between dirty and clean resident care and should have.

Based on observations and interview, the facility failed to ensure dietary services were provided in a sanitary environment for the 18 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure beard restraints were worn by all staff with beards in the kitchen area. The facility's census was 18 as documented on the facility's Resident Census and Condition of Residents form dated 5/29/18. Observation on 5/29/18 from 11:25 AM to 11:45 AM revealed S2, Kitchen staff preparing plates at the steam table with full beard and moustache with no beard restraint in use. During an interview on 5/29/18 at 11:45 AM S1, Dietary Manager stated the facility policy was for beard restraints to be worn when preparing trays to prevent hair from contacting food. S1, Dietary Manager agreed S2 Kitchen staff was not wearing a beard restraint and should be. S1, Dietary Manager stated 18 lunch trays were served from the kitchen.

Based on record reviews, interviews, and policy reviews the facility failed to develop and implement a written policy on reporting abuse and/or alleged abuse to the state agency. The facility failed to develop and implement a policy to report abuse and/or suspected abuse when resident (#1) was improperly restrained. According to the Resident Census and Conditions of Residents dated 5/8/18, 18 residents resided in the facility. Findings: Review of Grievance log revealed Resident #1 family member complained that on 4/27/18 Resident #1 was improperly restrained and sustained brusing. During an interview on 5/10/18 at 3:30 PM S1 Administrator stated the incident with Resident #1 was investigated and determined Resident #1 was improperly restrained. S1 Administrator stated the incident was a reportable occurrence and was reported to the parent hospital but not to the state agency. S1 Administrator further stated the facility did not have a policy for reporting abuse and/or suspected abuse to the state agency and the incident was not reported to the state agency. Review of Facility's Policy and Procedures failed to reveal a policy on reporting abuse and/or alleged abuse to the state agency.

Based on observations, record reviews, and interview the facility failed to maintain a medication error rate of less than 5%. A total of 10 residents were observed during the facility's medication pass administered by one LPN and one RN on 12/12/11 and 12/13/11. A total of 50 opportunities were observed which included 3 medication errors with two residents (#71, #215), for a medication error rate of 6%. Findings: 1. Observation on 12/12/11 at 11:11 a.m. during the medication pass, #S4 LPN adminnistered [MEDICATION NAME] 325mg to resident #215 before the noon meal and no food was offered with the medication. Review of resident #215's physician orders [REDACTED]. 2. Observation on 12/12/11 at 11:20 a.m. during the medication pass, #S4 LPN adminnistered [MEDICATION NAME] 1mg and [MEDICATION NAME] 25/100 to resident #71 before the noon meal and no food was offered with the medications. Review of #71's physician orders [REDACTED]. Further review of #71's physician orders [REDACTED]. During an interview on 12/12/11 at 3:00 p.m. with #S4 LPN she reviewed the physician orders [REDACTED]. #S4 LPN reviewed the physician orders [REDACTED].

Based on observations and interview, the facility failed to ensure dietary services were provided in a sanitary environment for 13 of 13 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure food was handled in a sanitary manner. Findings: Observation of the kitchen on 12/12/11 at 11:55 a.m. revealed #S5 dietary worker was preparing resident meals with gloved hands. Further observation revealed #S5 dietary worker handled plates, serving utensils, and then picked up rolls and cornbread with the soiled gloved hands. During an interview at that time #S3 Dietary Manager observed #S5 picking up the rolls and cornbread with her soiled gloved hands and agreed she should have used tongs to serve the rolls and cornbread.