The Ellington

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the state's Long-Term Care Ombudsman in writing of a discharge for 1 (#123) of 1 (#123) residents reviewed for discharge requirements out of a total sample of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the status of 2 (Resident #5 and #55) of 41 sampled residents. Resident #5Review of Resident #5's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertensive heart disease without heart failure, major depressive disorder, shortness of breath, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #5's current physician's orders revealed an order dated 03/08/2025 that read in part, Hydrochlorothiazide (diuretic) oral tablet 25 mg (milligrams) Give 25 by mouth one time a day. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement a person centered care plan by failing to ensure physician orders were followed for heel protectors for 1 (Resident #55) of 41 sampled residents. Review of Resident #55's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified sequelae of cerebral infarction, hypertensive heart disease without heart failure, anxiety disorder, unspecified and dermatitis. Review of Resident #55's current physician's orders revealed an order dated 01/09/2025 that read in part, Apply heel protectors every morning while patient is in bed every day shift. Review of Resident #55's care plan with a focus that read in part, Resident has potential for alteration in skin integrity related to impaired mobility and history of pressure ulcers. [...]

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the care plan for 1 (#80) of 2 (#9, #80) residents investigated for dialysis out of a sample of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing services were provided to meet standards of quality as evidenced by failing to ensure nurses conducted a fall risk assessment after each time a resident had a fall, and accurately assessed a resident's fall risk status for 1 (#3) out of 4 (#1, #2, #3, and #4) resident's investigated for falls.

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to assess the resident after receiving reports of bruising, swelling, and pain to the resident's right leg for 1 (#4) out of 4 (#1, #2 #3, #4) sampled residents.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to implement care plan interventions and provide adequate supervision to ensure a cognitively impaired resident, who had a history of wandering did not elope for 1 (Resident #1) out of 3 sampled resident (Resident #1, #2, and #3). This deficient practice resulted in an Immediate Jeopardy on 08/23/2024 at 6:51 p.m. when Resident #1, a severely cognitively impaired resident, was unsupervised and eloped from the facility. On 08/23/2024 beginning at 5:10 p.m., Resident #1 was observed by multiple staff members repeatedly attempting to open several doors throughout the facility before exiting the facility's front entrance door undetected by staff at 6:51 p.m. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure resident's remained free from accidents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) investigated for falls. The facility failed to ensure: 1. night staff got resident out of bed during last rounds, and 2. the resident's wheel chair alarm was properly working.

Inspectors wroteBased on observations and interview, the facility failed to maintain and clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#46) out of 2 (#24 and #46) residents investigated for homelike environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow a physician's order and care plan for 1 (#95) of 40 sampled residents by failing to ensure the resident's TED (Thrombo-Embolic Deterrent) hoses were applied as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored appropriately when not in use for 1 (Resident #97) out of 2 (Resident #83, Resident #97) sampled residents reviewed for respiratory care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#95) of 40 sampled residents. This was evidenced by S4LPN (Licensed Practical Nurse) leaving Resident #95's medication at the bedside.

Inspectors wroteBased on observations and interview, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Two opened packages of hamburger buns not labeled with the date. 2. Food storage: A. Cooler: 1. One opened Liquid Protein container not labeled with the date. 2. One opened Chocolate Desert Topping not labeled with the date and an expiration date of 03/31/2024. B. Walk-in freezer: 1. One opened bag of garlic bread not labeled with the date. 2. One opened bag of sweet potato fries not labeled with the date. The total amount of residents that ate out of the kitchen was 112 residents.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to accurately document on the TAR (Treatment Administration Record) for 1 (#98) out of 1(#98) sampled resident reviewed for urinary catheter or UTI (Urinary tract infection) in a final sample of 40 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring adverse reactions of Plavix and Aspirin for 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a chair to bed transfer for 1 (#1) of 4 (#1, #2, #3, and #R1) sampled residents. This deficient practice resulted in actual harm for Resident #1 on 03/25/2024 at 5:37 p.m. when S5CNA (Certified Nursing Assistant) transferred the resident from chair to bed without assistance of another person and without the use of a mechanical lifter as required by his plan of care. On 03/26/2024 at 10:30 a.m., S3ADONWC observed Resident #1's right lower leg as discolored and painful upon movement. X-ray of the resident's right lower leg, dated 03/26/2024, revealed a tibia (shin bone) fracture. On 03/29/2024 at 11:26 a.m., S9MD (Medical Doctor) observed swelling and discoloration to the resident's left lower leg and ordered an x-ray. [...]

Inspectors wroteBased on record reviews, interviews and observations, the facility failed to ensure the residents call system was functioning properly for 2 (Hall B and Hall C) of 3 halls (Hall A, Hall B and Hall C). The deficient practice was evidenced when: 1. Resident #2's RP (responsible party) filed a grievance regarding Resident #2 pressing her call bell, and staff failing to assist the resident because the call system was not functioning properly and 2. A bed alarm was tested on site in Room A and immediately after bed alarm was deactivated, the resident call system for 2 halls (Hall B and Hall C) began malfunctioning.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident's person-centered comprehensive care plan was implemented for 1 (#2) of 3 (#1, #2 and #3) sampled residents by failing to ensure Resident #2 had a working call light and received prompt response when the resident requested assistance.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement the residents' plan of care by not following physician orders and the care plan for 2 (#16, #105) out of a finalized sample of 38 residents as evidenced by: 1. Failing to ensure catheter tubing was secured by using a leg strap for resident #16, 2. Failing to monitor and document behaviors and adverse reactions to an antidepressant for resident #105. This deficient practice had the potential to affect a total census of 109 residents.

Inspectors wroteBased on observations, record review and interview the facility failed to meet the food preferences of 1 (#48) resident out of 3 (#44, #48, #54) residents investigated for food in a final sample of 38 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#11) out of 38 sampled residents. The facility had a census of 109 residents. Review of the resident's #11's electronic clinical record revealed Resident #11 was admitted to facility on 01/17/2023 with diagnosis not limited to: Right femur fracture, Unsteady Gait, Major Depression, Visual Hallucination, Abnormal weight loss and Macular Degeneration. Review of the physician's orders revealed an order dated 03/20/2023 - Admit to Amedisys Hospice. Review of the resident's significant change MDS (Minimum Data Set) dated 03/27/2023 revealed the resident was not coded for having hospice services. On 07/11/2023 at 1:50 p.m., an interview was conducted with S7LPN (Licensed Practical Nurse) who confirmed the resident is on Hospice services. [...]

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure that Resident #61 who was admitted to the facility with the diagnoses of Bipolar Disorder and Major Depressive Disorder had a Level I PASARR (Preadmission Screening and Resident Review) screening for 1 (#61) out of 2 (#43, #61) resident investigated for PASARR.

Inspectors wroteBased on observations, record review and interview, the facility failed to help prevent the development and transmission of communicable diseases and infections. Staff failed to perform hand hygiene after changing gloves during wound care for 1 (#16) of 1 (#16) residents investigated for pressure ulcers out of 3 residents with pressure ulcers according to the Resident Census and Conditions of Residents Report (CMS-672).