cms_TN
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 101 | 101 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2019-08-01 | 610 | D | 0 | 1 | 6GVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 (Resident #84) abuse incidents reviewed. The findings include: The facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy revised 12/11/17 documented, .INTERNAL INVESTIGATION POLICY .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident .The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .When there is a question as to whether to conduct an investigation, it is best to do so . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #84 on 7/29/19 at 9:05 AM, in her room, Resident #84 stated, .I was left wet all night. They (staff) didn't do anything. She (Certified Nursing Assistant (CNA)) said I shouldn't be lying about her. The next night they (staff) got on to her (CNA). The third night she (CNA) kissed me in the mouth and said she (CNA) loved me. Resident #84 was asked if she knew the CNA's name. Resident #84 stated, (Named CNA #1). She works midnights . Review of an untitled facility timeline presented by the Assistant Director of Nursing (ADON) on 7/29/19 regarding an incident with Resident #84 documented, .7/18/19 .(Named Resident #84) reported the CNA from 11p (pm)-7am shift had not change her (Resident #84) properly. Patient (Resident #84) states that at approximately 2-3 am she (Resident #84) put her call light on because she (Reside… | 2020-09-01 |
| 102 | 102 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2019-08-01 | 880 | D | 0 | 1 | 6GVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Infection Control Manual review, medical record review, observation, and interview, the facility failed to maintain infection control practices for 1 of 2 (Resident #60) sampled residents reviewed for urinary catheters and failed to provide effective [MEDICAL TREATMENT] communication for 1 of 2 (Resident #340) sampled residents reviewed for isolation. The findings include: 1. The facility's undated USE OF FOLEY CATHETER policy documented, .Follow the Physician order [REDACTED]. 2. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Indwelling Catheter change every month due to [MEDICAL CONDITION] Bladder/[MEDICAL CONDITION] . 3. Observations in Resident #60's room on 7/29/19 at 8:12 AM, 1:41 PM, and 5:26 PM, revealed Resident #60 was lying in the bed and his indwelling, urinary catheter bag was lying on the floor. Interview with the Director of Nursing (DON) on 7/31/19 at 2:33 PM, the DON was asked should the urinary catheter bag be lying on the floor. The DON stated, No, Ma'am. 4. The facility's Infection Control manual with a revision date of 10/1/08 documented, .It is the right of every patient in the center to receive a standard of care which includes a safe environment which prevents the transmission of infectious disease .The goals of the Infection Control Program .decrease the risk of infection to patients, partners and visitors . The facility's Nursing Home/[MEDICAL TREATMENT] agreement documented .The nursing home will inform (named clinic) of all relevant medical .information . 5. Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Contact Precautions .RELATED [MEDICAL CONDITION] BLOOD AND WOUND .[MEDICAL TREATMENT] every Tuesday, Thursday .and Saturday . Interview with Licensed Practical Nurse (LPN) #1 on 7/30/19 at 3:24 PM, in … | 2020-09-01 |
| 103 | 103 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2017-12-14 | 659 | D | 0 | 1 | 82QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure care plan interventions were followed for provision of activities of daily living (ADLs)/incontinence care and fall prevention for 2 of 23 (Resident #67 and 76) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/20/17 documented, .Requires extensive to total assist with most ADL's .frequently incontinent of bowel .APPROACHES .Check for incontinence q (every) 2 hrs (hours) and PRN (as needed), provide care . Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up yet. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 was lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Interview with CNT #1 on 12/11/17 at 1:01 PM, on the 300 hall, CNT #1 was asked what they normally do if a resident needed incontinence care provided during a meal pass. CNT #1 stated, We usually go in and change them. CNT #1 was asked whether it was appropriate to leave a resident waiting for incontinence care after an episode of bowel incontinence during an entire meal. CNT #1 stated, No. Interview with the Director of Nursing (DON) on 12/12/17 at 3:56 PM, in the conference room, the DON was asked when she expected staff to provide incontinence care to reside… | 2020-09-01 |
| 104 | 104 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2017-12-14 | 677 | D | 0 | 1 | 82QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure incontinence care was provided for 1 of 1 (Resident #67) sampled resident reviewed for activities of daily living (ADL) care. The findings included: 1. The facility's INCONTINENT CARE policy documented, .PURPOSE .Designated partners to giveincontinent (give incontinent) care for those patients incontinent of bowel and/or bladder .OBJECTIVE .Prevent Infections .Prevent Odors .Provide comfort to perineal area caused by irritation, infection, or incisions .Prevent skin irritation . 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment, required extensive assistance with toilet use and personal hygiene, and was frequently incontinent of bowel. Review of the care plan dated 10/20/17 revealed, Resident #67 required extensive to total assist with most ADLs and was frequently incontinent of bowel. Interventions included to check for incontinence every 2 hours and as needed and provide care. Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Intervie… | 2020-09-01 |
| 105 | 105 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2017-12-14 | 689 | E | 0 | 1 | 82QH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure fall prevention measures were followed for 2 of 4 (Resident #18 and 76) sampled residents reviewed for falls. The findings included: 1. The facility's undated GAIT BELTS policy documented, .Designated partner will use a gait belt during ambulation or movement of the patient who needs security and assistance .Objective .Provide increased security for the patient and staff .Prevent injury during movement of patient .Use the belt during walking to stabilize the patient .If patient begins to fall, use the gait belt to .Draw patient close to your body with the belt .Gently and slowly lower patient to the floor by allowing the patient to slide down your leg . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment, required extensive staff assistance with transfers, walking did not occur, and Resident #18 had 1 fall in the month prior to admission. The Post Falls Nursing assessment dated [DATE] documented, .Fall in room ambulating to bathroom . The Fall Scene Investigation Report dated 10/2/17 documented, .(Certified Nursing Technician (CNT) #4) (with) pt (patient) (and) lowered to floor .root cause of the fall .Became weak . The SCREENING FORM PAGE 2 documented, .S/P (status [REDACTED].Pt was ambulating to bathroom (with) CNT and went to floor. Was using rw (rolling walker) and CNT reports pt was trying to amb (ambulate) too quickly (and) did not slow (with) verbal cues .followed up personally (with) this CNT. Educated her on how use of gait belt could have given her more control (with) pt to both slow her down (and) slow fall . Review of a hospital history and physical dated 10/31/17 revealed a [DIAGNOSES REDACTED]. Observatio… | 2020-09-01 |
| 106 | 106 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2019-01-07 | 609 | D | 1 | 0 | Y9FF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure allegations of abuse were reported timely to the facility's Administrator and to the state survey agency for 4 residents (#1, #2, #3, and #4) of 8 residents reviewed for abuse on 1 of 4 nursing units. The findings included: Review of facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation, last reviewed 6/2018, revealed .policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations . Medical Record Review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 3/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident exhibited physical and verbal behaviors directed toward others and required total care for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #1's care plan dated 11/16/18 revealed the resident was care planned for episodes of combativeness during care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #2 was assessed as severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident required total assistance for bed mobility, toilet use, dressing, and personal hygiene. Medical record review of Resident #2's care plan dated 9/19/18 revealed the resident would smack at staff during care received for Activities of Daily Living (ADL). Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quar… | 2020-09-01 |
| 107 | 107 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2017-02-08 | 309 | D | 0 | 1 | F38S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#27) of 5 residents reviewed for unnecessary medication of 35 sampled residents. The findings included: Medical record review revealed Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #27's Care Plan dated 11/23/16 revealed .The resident uses [MEDICAL CONDITION] Medications .[MEDICATION NAME] .Administer [MEDICAL CONDITION] medications as ordered by physician .monitor for side effects and effectiveness q (every) shift . Medical record review of a Psychiatric Consult dated 1/13/17 revealed .suggest .1. D/C (discontinue) [MEDICATION NAME] to eval (evaluate) for need . Medical record review of Physician order [REDACTED].[MEDICATION NAME] (antidepressant medication) Tablet 10mg (milligram) Give 1 tablet by mouth one time a day related to Anxiety Disorder . Medical record review of Physicians Orders dated 1/17/17 revealed .TO (telephone order) .D/C [MEDICATION NAME] . Medical record review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1 on 2/7/17 at 1:35PM, at the 2nd floor Nurses station confirmed [MEDICATION NAME] had been discontinued on 1/17/17 but Resident #27 continued to receive the medication until 1/30/17, 13 days after the medication was discontinued. | 2020-09-01 |
| 108 | 108 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2017-02-08 | 371 | F | 0 | 1 | F38S11 | Based on the facility policy, observation, and interview, the facility failed to dispose of left overs in 1 of 3 refrigerator/coolers by the use by date (UBD), failed to properly store pans and failed to ensure kitchen equipment and non-food contact surfaces were clean and maintained in a sanitary manner, affecting 62 of 74 residents. The findings included: Review of the facility policy Infection Control Sanitation and Storage dated/revised 1/2010 revealed .Any prepared refrigerated foods that are to be used for leftovers are to be covered and dated. And discarded after the (3) third day and not to be used .provide clean .storage and work areas .General Responsibilities: the highest level of sanitation in the areas of food, equipment, work surfaces .maintaining a safe and sanitary work area .equipment cleanliness .Pots and pan are to be air dried . Observation with the Certified Dietary Manager (CDM) on 2/6/17 at 10:00 AM in the kitchen, revealed: a). A can opener with debris on the blade. b). A Commercial mixer with dried debris on the beater shaft and outside rim. Observation with the CDM on 2/6/17 at 10:10 AM, in the kitchen, revealed the following pans stored wet and available for use: a). 2 of 11 four inch 1/2 steamtable pans b). 1 of 12 four inch 1/4 steamtable pans c). 1 of 6 two inch full steamtable pans d). 1 of 6 two inch full steamtable pans with dried debris on the inside of the pan. Observation with the CDM on 2/6/17 at 10:15 AM, in the kitchen, revealed the hood vents with dusty debris. Observation with the CDM on 2/6/17 at 10:20 AM, of the walk-in cooler, in the kitchen revealed these items stored after the UBD and available for resident consumption: a). One 4 inch 1/8 pan 1/2 full of chopped chicken b). One 2 pound container full of refried beans c). One 4 inch 1/8 pan full of taco meat d). One 6 inch 1/8 pan full of rice e). One 4 inch 1/4 pan full cream of chicken soup f). One 1 quart container 1/4 full of ketchup g). One 4 inch 1/6 pan 1/3 full of pasta salad. Observation with the CDM on 2/7/17… | 2020-09-01 |
| 109 | 109 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2018-03-08 | 641 | D | 0 | 1 | WN2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an accurate assessment for 1 resident (Resident #50) of 32 residents reviewed. The findings included: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #50 received an anticoagulant (a blood thinning medication used to treat, prevent, and reduce the risk of blood clots). Medical record review of the electronic physician's orders [REDACTED].#50 was prescribed an anticoagulant. Interview with the MDS nurse on 03/07/18 at 9:50 AM, in the conference room, confirmed Resident #50 did not receive an anticoagulant and the MDS assessment dated [DATE] was inaccurate. | 2020-09-01 |
| 110 | 110 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2018-03-08 | 656 | D | 0 | 1 | WN2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record and interview, the facility failed to follow the comprehensive care plan for 1 resident (Resident #44), of 4 residents reviewed for constipation, of 32 residents reviewed. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation.Monitor/document bowel sounds (decreased or absent bowel sounds may indicate constipation) and frequency of BM (bowel movement): provide laxative of choice per facility protocol (to include suppository (a medication inserted into the rectum used to treat constipation), enema (injection of fluid into the bowel to stimulate stool evacuation), MOM (Milk of Magnesium to treat constipation), [MEDICATION NAME] (stimulate laxative), [MEDICATION NAME] (stool softener), and Prune juice if no BM for more than 48 hrs (hours). Medical record review of Resident #44's daily Bowel Program flow sheets (a documentation tool for tracking daily bowel habits and medications administered for bowels) dated 9/1/17 to 3/6/18 revealed the following: September 2017 - 10 consecutive days, from 9/10/17-9/19/17, without documentation of a BM and no stool softener or laxative intervention. October 2017 - 7 consecutive days, from 9/28/17-10/4/17, without documentation of a BM and with no stool softener or laxative intervention, resulting in Resident #44 requiring disimpaction (manual removal of hard stool from the rectal cavity) on 10/22/17. Novemb… | 2020-09-01 |
| 111 | 111 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2018-03-08 | 690 | D | 0 | 1 | WN2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a bowel protocol for 1 resident (Resident #44) of 4 residents reviewed for constipation. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's Physician orders [REDACTED]. Medical record review of the Physician's Routine Orders dated 6/1/16 revealed, .laxative of choice. Continued review revealed no administration instructions to include what medication, dosage, frequency, and route. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation as defined by 2 or fewer bowel movements during look back period.Monitor/document bowel sounds and frequency of BM (bowel movement): provide laxative of choice per facility protocol if no BM for more than 48 hrs (hours). Medical record review of the facility's Bowel Program sheet, undated, revealed the following bowel management interventions: suppository (medication inserted into the rectum used to treat constipation), enema (injection of fluid into the lower bowel by way of the rectum to stimulate stool evacuation), Milk of Magnesia (MOM) (medication used to treat constipation), [MEDICATION NAME] (stimulant laxative), [MEDICATION NAME] (stool softener), and prune juice. Continued review revealed no administration instructions to include type of suppository and/or enema to administer. Further review revealed no administration instructions to include dosage, frequen… | 2020-09-01 |
| 112 | 112 | CLAIBORNE HEALTH AND REHABILITATION CENTER | 445071 | 1850 OLD KNOXVILLE ROAD | TAZEWELL | TN | 37879 | 2018-03-08 | 695 | D | 0 | 1 | WN2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility in-service, observation, and interview, the facility failed to implement [MEDICAL CONDITION] (a tube inserted in the neck to allow air to enter the lungs) suctioning equipment to care for 1 resident (Resident #34) of 1 reviewed for a [MEDICAL CONDITION], of 32 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility in-service (education) dated 2/7/18 revealed .In Service on Oxygen and Suction Equipment.All tubing (Nebulizer (a breathing machine used to administer inhaled medications into the lungs), Oxygen, Suction) will be changed once per week and dated.All suction cans will be changed when soiled and replaced with a new one, and dated. Observation with Registered Nurse (RN #1) on 3/6/18 at 7:22 AM in the resident's room, revealed a suction canister (un-dated), on Resident #34's end table, with secretions approximately 1/4 full, and the suction tubing was dated 2/19/18. Interview with RN #1 on 3/6/18 at 7:30 AM, at the unit 1 nurse's station, confirmed the suction tubing was out dated and should be changed every 7 days. The facility failed to implement the facility inservice education. | 2020-09-01 |
| 113 | 113 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 623 | E | 0 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to send notification of transfer to the hospital to the Ombudsman for 4 residents (#9, #11,#22, and #30) of 39 residents reviewed. The findings include: Review of the facility policy, Transfer/Discharge Notice, dated 12/6/16 revealed .The facility will send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 was transferred to the hospital. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #11 was transferred to the hospital on [DATE]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #22 was transferred to the hospital on [DATE]. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #30 was transferred to the hospital on [DATE]. Interview with the Social Worker on 1/15/19 at 1:50 PM in her office revealed she did not know she had to contact the Ombudsman when a resident was transferred or discharged from the facility. Further interview revealed the transfer and discharge notification to the Ombudsman had not been done since (MONTH) (YEAR). Interview with the Administrator and Director of Nursing (DON) on 1/15/19 at 1:57 PM in the Administrator's office confirmed the facility had not notified the Ombudsman when a resident transferred or discharged from the facil… | 2020-09-01 |
| 114 | 114 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 690 | D | 1 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain physician orders [REDACTED].#25) of 39 residents reviewed. The findings include: Review of the undated facility policy, Physician Orders, revealed .orders given by Physician/Medical Practitioner .notification to family/POA (Power of Attorney) via telephone .New order documented in nursing notes that order was received and family notified . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #25's physician's orders [REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Medical record review of Resident #25's Daily Skilled Nurse's Notes for 12/1/18 thru 12/10/18 revealed no documentation regarding an order for [REDACTED].>Interview with Resident #25 on 1/13/19 at 9:24 AM in her room revealed she stated The head nurse (the former Director of Nursing (DON)) came to help put a catheter in one evening, not sure if there was an order or not. Continued interview revealed she reports there were several people in the room trying to help place the catheter. She stated the nurse, the one not here because she was fired, asked her if she could place the catheter to get a urine sample because she was sick. She stated the nurse told me she was worried about me. I told her she could go ahead and put the catheter in. Continued interview revealed she stated I asked her if she had an order and she said yes. Interview with the Nurse Practitioner on 1/13/19 at 11:29 AM in the West dining room confirmed an order was not obtained for Resident #25 to be catheterized. Interview with Registered Nurse (RN) #4 on 1/14/19 at 3:49 PM at the North hall nursing station revealed she assisted the former DON in performing an intermitte… | 2020-09-01 |
| 115 | 115 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 695 | D | 0 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician order for [REDACTED]. The findings include: Review of the facility policy, Physician Orders, reviewed 6/1/15, revealed an order given by the Physician/Medical Practitioner .Nurse receiving order is responsible for complete order documentation . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #108 had received oxygen while not a resident in the facility and received oxygen while a resident at the facility. Medical record review of the physician orders revealed no orders for oxygen administration. Observation on 1/13/19 at 8:50 AM, 11:25 AM, 11:45 AM, 11:56 AM, 2:47 PM, and 3:32 PM revealed Resident #108 was in the room, in bed, nasal cannula in use, and the oxygen concentrator in operation set at 2 liter per minute (lpm). Observation on 1/14/19 at various times during the day revealed Resident #108 in the room, in bed, nasal cannula in place, and oxygen concentrator set at 2 lpm. Observation on 1/15/19 at 10:13 AM in Resident #108's room, with the Director of Nursing (DON) present, revealed the resident in bed with the nasal cannula in place and the oxygen concentrator operating at 2 lpm. Interview with Certified Nurse Aide (CNA) #5 on 1/15/19 at 10:13 AM at the South nursing station revealed she had cared for Resident #108 since the resident's admission. When asked how long the resident had been using oxygen the CNA stated .since admission . Interview with the DON on 1/15/19 at 10:20 AM at the North/East nursing station confirmed Resident #108's admission orders [REDACTED]. The DON confirmed the medical record for Resident #108 did not have oxygen orders. The DON stated she expected nurses to have orders for the oxygen. Interview with Licensed Practical Nurse (LPN) #2 on … | 2020-09-01 |
| 116 | 116 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 812 | F | 0 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to handle food in a sanitary manner when assisting residents with meals for 1 resident of 15 residents in the dining room. The facility dietary department failed to maintain dietary equipment in a sanitary manner; failed to maintain sanitizer in the sanitizer container used to sanitize work surfaces; and failed to operate the dish machine with sanitizer in 1 of 6 observations of the dietary department. The findings include: Review of the facility policy, Assistance with Meals, revised 6/27/18 revealed, .Employees who provide resident assistance with meals shall demonstrate competency in prevention of foodborne illness, including personal hygiene practices and safe food handling . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #5 required total one person assist with eating. Observation on 1/13/19 at 12:15 PM in the East dining room at the noon meal revealed Registered Nurse (RN) #1 picked up a roll from Resident #5's plate with her bare hands and attempted to give Resident #5 a bite of the roll and also attempted to put the roll in the residents hand. Interview with RN #1 on 1/13/19 at 12:16 PM in the East dining room revealed, RN #1 stated I have been feeding people like that for [AGE] years. I need to get a glove when handling residents food. Interview with the Director of Nursing on 1/14/19 at 8:50 AM in her office confirmed staff should never touch any resident's food with their bare hands. Observation on 1/13/19 at 9:02 AM in the dietary department walk-in refrigerator revealed a build-up of blackened debris and white debris on the condenser grate. Observation on 1/14/19 at 10:45 AM in the dietary department, with the Certified Dietary Manager (CDM) present, revealed the can opener blade tip and where the blade attached to the handle… | 2020-09-01 |
| 117 | 117 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-01-15 | 919 | D | 0 | 1 | W7UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a call light for 1 resident (#37) of 59 residents. The findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/13/19 at 9:54 AM, 11:52 AM and 2:50 PM in Resident #37's room revealed no call light available for the resident. Interview with Registered Nurse (RN) #2 on 1/13/19 at 2:52 PM in Resident #37's room confirmed she did not have call light. Interview with the Director of Nursing (DON) on 1/13/19 at 9:01 AM in her office when questioned about who was responsible for ensuring residents have a call light, the DON stated, .Everyone, anybody assigned to the room is . The DON confirmed all residents should have a call light available. | 2020-09-01 |
| 118 | 118 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-02-22 | 725 | E | 1 | 0 | BOIT11 | > Based on review of the facility nurse staffing schedules and interviews the facility failed to have sufficient nursing staff to provide nursing and related services and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the staffing schedule for 2/10/18. The findings included: Review of the facility nurse staffing for 2/10/18 revealed 3 CNAs were scheduled for the 3:00 PM to 11:00 PM shift. 1 of 3 scheduled CNAs was present to work the evening shift. CNA #3 worked the 7:00 AM to 3:00 PM shift and stayed over to help cover the evening shift. Interview with Resident #2 on 2/20/18 at 12:15 PM in the resident's room revealed he was cognitively intact and stated the facility was understaffed for the evening shift on 2/10/18 with only 1 of the scheduled CNAs showing up to work. Further interview with Resident #2 revealed CNA #3 worked a double to help cover the evening shift on 2/10/18. Continued interview with Resident #2 revealed the medications were administered .about an hour late . on evening shift for 2/10/18. Interview with Resident #4 on 2/22/18 at 1:40 PM in the resident's room revealed he was cognitively intact. He stated the facility staffing is frequently short. He also stated he required assistance to get in and out of the bed. He further stated he prefers to be in bed by 8:30 PM and on the evening shift of 2/10/18 he was not assisted into bed until between 10:00 PM and 11:00 PM. Interview with CNA #1 on 2/21/18 at 8:40 AM in the north hall revealed she worked the day shift on 12/31/17. Continued interview revealed CNA #1 stated only 1 CNA was in attendance to work the 3:00 PM to 11:00 PM shift. Interview with RN #4 on 2/21/18 at 8:45 AM in the north hall revealed she worked the evening shift for 2/10/18. Continued interview revealed she stated the medications were given approximately 1 hour late. Further interview revealed some residents were not assisted into bed at their usual preferred times. Interview with CNA #5 on 2/21/18 at 1… | 2020-09-01 |
| 119 | 119 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-05-15 | 921 | E | 1 | 0 | 2DLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, and interview the facility failed to maintain the physical environment in a safe and sanitary manner for 22 bathrooms out of 31 bathrooms observed. The findings included: Review of facility policy, Infection Control, revised 10/2018, revealed .The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infection .The QAPI Committee through the Infection Control; Committee, shall establish, review, and revise infections control policies and practices, and help department heads and managers ensure they are implemented and followed . Observation of the facility during tours on 5/14/19 and 5/15/19 revealed the following: room [ROOM NUMBER] - loose faucet; missing toilet seat room [ROOM NUMBER] - room trash can overflowing; urine odor room [ROOM NUMBER] - diaper on bathroom floor; dirty water in commode room [ROOM NUMBER] - brown debris in toilet bowl; basin on floor with used gloves and cleansers in it Rooms 8 & 10 share bathroom - unflushed toilet room [ROOM NUMBER] - clothes on bedside table and floor room [ROOM NUMBER] - strong urine odor; dirty linen in sink Rooms 12 & 14 - strong smell of urine in bathroom Rooms 15 & 17 - bathroom trash can overflowing Rooms 16 & 18 - dirty water in commode with brown particles in bowl Shower room - drain without cover room [ROOM NUMBER] - powder on toilet seat and floor; strong urine odor; colored water in toilet room [ROOM NUMBER] - urine in toilet room [ROOM NUMBER] - diaper and pitcher on overbed table; lift sling on bedside table; brown material on toilet bowl; soiled linen on floor, in sink, and on toilet tank room [ROOM NUMBER] - dirty streaks in toilet; trash can full room [ROOM NUMBER] - 1 unlabeled bedpan on floor and 1 unlabeled bedpan on bathroom rail room [ROOM NUMBER] - diaper in chair and clothes as well room… | 2020-09-01 |
| 120 | 120 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-06-23 | 282 | G | 1 | 0 | Q80711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review and interview the facility failed to follow the resident's care plan to ensure safe transfer techniques were implemented for 1 resident (#1) of 9 residents reviewed for abuse of 11 residents sampled. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistan… | 2020-09-01 |
| 121 | 121 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-06-23 | 323 | G | 1 | 0 | Q80711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review, and interview the facility failed to ensure safe transfer techniques were implemented for 1 resident (#1) of 1 resident reviewed for injury of unknown origin of 11 residents reviewed. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name (sit to stand lift)) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer (care giver) in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required … | 2020-09-01 |
| 122 | 122 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 558 | G | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility record review and interview, the facility failed to ensure reasonable accommodation of needs to prevent decline for 1 (#22) of 38 residents reviewed resulting in psychosocial and physical Harm for Resident #22. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #22 required extensive assistance of 1 staff member for bed mobility and 2 staff members for transfers. Medical record review of the Progress Notes Report dated 4/8/19 revealed .Maintenance man reported to this nurse, f/u (follow up) with resident regarding having his bed replaced. (named medical equipment provider) delivered bed for resident in the interim, so maintenance can work/replace the parts to the existing bed . Resident #22 was transferred to the rental bed at this time. Medical record review of the service document from the rental company dated 4/9/19 revealed the order requisition sheet for a rental bariatric bed. Continued review revealed .5/8/19 fixed . Medical record review of the Former Nurse Practitioner (NP) notes dated 4/25/19 revealed .Patient appears hemodynamically stable, afebrile, nontoxic, but presents with left lower extremity [MEDICAL CONDITION] (bacterial infection of the skin) in the setting of chronic [MEDICAL CONDITION] .Elevate extremities . Medical record review of the Former NP notes dated 5/19/19 revealed .As such, it is medically necessary that the bed be changed to one that will allow extremity elevation, as this patient is rather immobile and morbidly obese and does suffer from marginally compensated heart failure and chronic [MEDICAL CONDITION] now presenting with [MEDICA… | 2020-09-01 |
| 123 | 123 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 580 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to notify the physician when there was a significant change in condition for 1 (#22) of 38 residents reviewed. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident #22's Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #1 revealed, .called to Resident's room to evaluate [MEDICAL CONDITION] area to right thigh area .area cleansed and maggots removed . Medical record review of Resident Progress Notes dated 6/18/19 written by LPN #2 revealed, .called to Resident's (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) per request. Telephone interview with LPN #2 on 8/14/19 at 2:02 PM revealed she had not called the Nurse Practitioner (NP) or Medical Director (MD) #2. Interview with LPN #1 on 8/14/19 at 3:38 PM in the West Dining Room confirmed she did not notify the NP or MD #2 on 6/18/19 when the maggots were discovered and Resident #22 was transferred to the hospital. Telephone interview with the Former MD #2 on 8/14/19 at 10:29 AM confirmed he was not notified of the maggots, increased [MEDICAL CONDITION], or transfer to the hospital on [DATE]. Telephone interview with the NP on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (na… | 2020-09-01 |
| 124 | 124 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 600 | J | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, service reports, observation, and interview, the facility failed to prevent neglect for 3 (#1, #16, and #22) of 38 residents reviewed. The facility failed to provide needed care and services to prevent the infestation of fly larvae (maggots) in subcutaneous tissue (underneath the skin) and under skin folds for 1 (#22) of 5 residents reviewed. The facility failed to monitor and document bowel movements and failed to administer appropriate bowel medications for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to prevent actual abuse to 1 (#23) of 38 residents reviewed. Actual Harm occurred when Residents #1 and #16 complained of severe abdominal pain and constipation necessitating a visit to the hospital. The facility's non-compliance resulted in Residents #1 and #16 psychological and physical harm. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on [DATE] at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on [DATE] at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] - [DATE]. F689 is Substandard Quality of Care. Noncompliance continues at a scope and severity of D to monitor the effectiveness of the corrective actions. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised ,[DATE], revealed .It is the … | 2020-09-01 |
| 125 | 125 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 609 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, State Survey Agency Facility Reported Incidents database review, and interview, the facility failed to report neglect to the State Survey Agency for 1 (#22) of 38 residents reviewed. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised 5/2019, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator, or designee, will investigate all such allegations .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed on 6/18/19 CNA #… | 2020-09-01 |
| 126 | 126 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 641 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete an accurate assessment of the resident status for 3 (#5, #14, and #21) of 38 residents reviewed. The findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 14 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers, toileting, and bathing; required extensive assistance of 2 people with dressing and grooming; frequently incontinent of bowel; and had a suprapubic urinary drainage catheter in place. Medical record review of the Annual MDS dated [DATE] for Resident #5 revealed in the section on Bowel and Bladder, under Appliances it was documented as none of the above but the space for suprapubic catheter should have been marked. Under urinary continence it was marked not rated, resident had a catheter. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #14 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #14 required total dependence with 2 staff members for bed mobility and transfers. Continued review revealed Resident #14 required extensive assistance with 1 staff member for toileting. Continued review revealed Resident #14 was frequently incontinent of bowel. Continued review revealed Resident #14's use of a condom catheter was not addressed in the Bowel and Bladder section. Interview with the Corporate Nurse on 8/21/19 at 2:33 PM in the Social Services office confirmed the facility failed to capture the condom catheter on the Admission MDS. … | 2020-09-01 |
| 127 | 127 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 656 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to have an updated care plan for 1 (#22) of 38 residents reviewed. The findings include: Review of the facility policy Comprehensive Care Plans revised 7/19/18 revealed .The Comprehensive Care Plan will be person-centered to include the discharge plans to meet the resident's preference and goals to address the resident's medical, physical, mental and psychosocial needs . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of the Physician's Order Sheet dated 5/19/19 revealed .TREATMENT/PR[NAME]EDURE .ELEVATE LEGS AT ALL TIMES . Medical record review of the care plan dated 6/18/19 and 7/4/19 revealed the care plan was not revised to reflect orders to elevate Resident #22's legs at all times. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed the he had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (the bed) needed to be fixed . It would not elevate his legs. Interview with the Corporate Nurse on 8/21/19 at 12:53 PM in the Social Services office confirmed the facility failed to update Resident #22's care plan to include elevation of the legs. | 2020-09-01 |
| 128 | 128 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 658 | F | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide care according to professional standards of practice by failing to monitor bowel movements; failing to intervene according to facility policy and physician's orders [REDACTED].#1,#5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to document nursing information for 3 (#1, #4, and #16) of 38 residents reviewed. The findings include: Review of facility policy, BM Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7… | 2020-09-01 |
| 129 | 129 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 695 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation and interview the facility failed to date and change oxygen tubing and humidifier canisters for 1 (#21) of 5 residents reviewed with oxygen. The findings include: Review of the facility policy Oxygen Administration dated 9/6/18 revealed .Check the mask, tank, humidifier canister, etc. (when in use), to be sure they are good working order and are securely fastened. Be sure there is water in the humidifier canister and that the water level is high enough that the water bubbles as oxygen flows through . Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the care plan revised on 3/29/19 revealed .increase oxygen to 4 liters per nasal cannula . Observation and interview with Resident #21 on 8/5/19 at 11:24 AM in his room revealed the resident was lying in bed with his head elevated at a 45 degree angle and wearing a hospital gown. Continued observation revealed the resident was receiving oxygen therapy by nasal cannula. Further observation revealed the humidifier canister was not dated. Observation and interview on 8/6/19 at 8:59 AM in Resident #21's room revealed he had nasal cannula in place but the prongs were not in his nostrils. Continued interview with Resident #21 revealed when asked if he was comfortable with the prongs not in his nostrils the resident stated his nose was hurting. Continued observation revealed the humidifier canister was empty and undated. Interview with Registered Nurse (RN) #1 on 8/6/19 at 9:11 AM in Resident #21's room revealed RN #1 confirmed the humidifier canister was out of water and not dated. Interview with the Interim Director of Nursing (DON… | 2020-09-01 |
| 130 | 130 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 755 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to obtain Physicians' Orders for a medicated solution and failed to ensure that only licensed personnel administered medications for 1 (#22) of 38 residents reviewed. The findings include: Record review of the facility policy Medication Administration General Guidelines revised 9/6/18 revealed .Medications are prepared and administered only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare and administer medications . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Medical record review of the Physicians' Order Sheets and Physician's Telephone Orders dated (MONTH) 2019 revealed no orders for Dakin's (a dilute hypochlorite (bleach) antibiotic solution. It kills the microorganisms but also harms healthy skin in all concentrations) solution for Resident #22. Interview with Resident #22 on 8/7/19 at 1:26 PM in his room revealed Certified Nurse Aide (CNA) #2 and CNA #3 began to cleanse the plaques and fissures by pouring a solution (Dakin's) on the area. Continued interview with Resident #22 revealed the Wound Care Nurse (LPN #1) gave t… | 2020-09-01 |
| 131 | 131 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 835 | J | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interviews Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The inactions and decisions of Administration contributed to physical and psychosocial harm for 3 (#1, #16, #22) of 38 residents reviewed. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on 8/21/19 at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on 8/21/19 at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 8/21/19. The Immediate Jeopardy was effective from 6/18/19 - 8/21/19. The findings include: Review of Pest control customer service reports (This report is provided to identify sanitation deficiencies, structural defects and improper storage practices contributing to pest infestation.) revealed: 2/20/19 Small flies noted during service in kitchen .Reviewed with management . 3/20/19 Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies noted in … | 2020-09-01 |
| 132 | 132 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 842 | F | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Medical record review and interview the facility failed to maintain complete medical records for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements and /or treatments. The findings include: Review of facility policy, BM (Bowel Movement) Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the Nurse's Notes confirmed there were no Nursing Notes available from admission on 2/23/18 to discharge on 7/9/19 including the incident which precipitated he… | 2020-09-01 |
| 133 | 133 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 880 | D | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, observation and interview the facility failed to change the dressing and have a legible date on a PICC (Peripherally Inserted Central Catheter) (a catheter inserted in a peripheral vein and threaded to a vein close to the heart used for prolonged IV (intravenous) medications) for 2 (#31 and #32) of 2 residents reviewed with PICC lines. The findings include: Review of the facility policy Dressing Change For Vascular Access Devices dated 8/1/16 revealed .Central venous access device and midline dressing changes will be done at the established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected .Transparent semi-permeable membrane (TSM) dressing are changed every 7 days and PRN (as needed) .All catheters - Apply label on dressing with date and nurse's initials. Do not write on TSM dressing with pen or magic marker . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 required IV medications. Medical record for Resident #31 review of the Physician Order Report dated 8/1/19-8/7/19 revealed Resident #31 received .dressing change PRN (as needed) soiling or dislodgement Special Instruction: Date and time dressing for change and readjust standing Midline schedule change . Observations on 8/5/19 at 2:37 PM and on 8/7/19 at 9:50 AM in Resident #31's room revealed the PICC line to the right upper arm had gauze over the insertion site and a transparent dressing over the site with illegible writing on the dressing. Observation and interview on 8/7/19 at 2:06 PM in Resident #31's room with the Nurse Practitioner (NP) revealed the same dressing on the PICC line with illegible writing on it. Continued interview with the NP confirmed during e… | 2020-09-01 |
| 134 | 134 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 921 | E | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure a sanitary environment for the residents in 10 (#9, #16, #20, #23, #25, #34, #36, #42, and #44) of 30 rooms observed. The findings include: The initial facility tour revealed the following findings: Observation on 8/5/19 at 10:30 AM in room [ROOM NUMBER] revealed brown debris in the toilet. Observation on 8/5/19 at 10:40 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. Observation on 8/5/19 at 10:46 AM in room [ROOM NUMBER] revealed an odor resembling old urine in the room. Observation on 8/5/19 at 10:51 AM in room [ROOM NUMBER] revealed the toilet seat had brown debris on it and there was yellow liquid in the toilet. Observation on 8/5/19 at 10:55 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. These findings were confirmed on 8/5/19 at 11:30 AM with the nurse on the unit, LPN #2. Observation on 8/5/19 at 10:51 AM in the bathroom of room [ROOM NUMBER] revealed the soap dispenser cover was missing and there was no soap in the bathroom for the residents to use. Observation on 8/5/19 at 11:20 AM in the bathroom of room [ROOM NUMBER] revealed the ADON attempted to wash her hands but there was no soap in the bathroom. Continued observation confirmed the ADON left the bathroom; came back with body wash soap to wash her hands; and placed the body wash soap on the bathroom sink. Observation on 8/5/19 at 11:24 AM, 2:02 PM and 3:45 PM in the bathroom of room [ROOM NUMBER] revealed 2 unlabeled bed pans and 2 unlabeled wash basins on the floor 1 on each side of the toilet. Interview with Resident #32 on 8/5/19 at 1:32 PM in his room revealed he asked for a bar of soap and a staff member told him a soap dispenser was needed. Continued interview with the resident revealed .they just put in a dispenser today . Interview with Maintenance Director on 8/5/19 at 3:18 PM in the West dining room revealed… | 2020-09-01 |
| 135 | 135 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2019-08-21 | 925 | F | 1 | 0 | J49Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, pest control customer service report review, facility observation, and interview, the facility failed to maintain an effective pest control program to prevent infestation of insects (flies and gnats) in the kitchen, hallways, and resident rooms. The findings include: Review of the facility policy titled Pest Control dated (MONTH) 2005 revealed .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided by (named pest control service) .Maintenance services assist, when appropriate and necessary, in providing pest control services. Record Review of Pest control customer service reports revealed: 2/20/19 .Small flies noted during service in kitchen .Reviewed with management . 3/20/19 .Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies in hallways .Reviewed with Management . Record Review of the Life Safety/Plant Ops Communication Report dated 7/8/19 revealed .drain lines, cleaning . Observation on 8/5/19 though 8/21/19 revealed the Illuminated Light Trap (to attract flies and gnats) was not working on the back hall on the right. Observation on 8/8/19 at 9:30 AM in rooms [ROOM NUMBERS] revealed gnats and flies. Continued observation on 8/8/19 at 9:45 AM revealed gnats and flies in the women's public restroom. Continued observation on 8/8/19 at 10:00 AM revealed flies and gnats in the West dining room. Observation on 8/8/19 at 2:00 PM in … | 2020-09-01 |
| 136 | 136 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-09-25 | 600 | J | 1 | 0 | IY3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility neglected to provide necessary services to a reisdent by failing to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toiletin… | 2020-09-01 |
| 137 | 137 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-09-25 | 656 | J | 1 | 0 | IY3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to implement the Care Plan for a resident who was found unresponsive with no pulse or respirations who was a full code (life saving measures to include chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death; and failed to supervise a resident adequately to prevent his elopement from the facility for 1(Resident #10) of 9 records review for elopement. This failure placed Resident #10 and #11 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE] and [DATE] - [DATE]. The findings include: Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated ge… | 2020-09-01 |
| 138 | 138 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-09-25 | 658 | J | 1 | 0 | IY3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow acceptable standards of clinical practice by failing to perform Cardiopulmonary Resuscitation (CPR) on a resident who was a found unresponsive with no pulse or respirations who was a full code (chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving resident medical record. 2. Assess resident for status of breathing and check for pulse. 3. Check the medical record for advance directive status. 4. Retrieve emergency cart and Automated Externa… | 2020-09-01 |
| 139 | 139 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-09-25 | 678 | J | 1 | 0 | IY3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to adequately monitor and intervene for a serious medical condition when a Registered Nurse (RN) failed to perform cardiopulmonary resuscitation (CPR) on a resident who was found unresponsive with no pulse or respiration who was a full code (life-saving measures to include chest compressions, airway management, medications, and transfer to hospital) for 1 (Resident #11) per investigation of 9 records, 6 of which did not have advanced directives; 1 did not have a POST; and 1 POST was signed 2 weeks after it was initially written. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving … | 2020-09-01 |
| 140 | 140 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2018-09-25 | 689 | J | 1 | 0 | IY3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Review of undated facility policy, Missing Resident, revealed .Notify the Charge Nurse .Room to room check will be conducted to identify all residents .Check all areas of the facility including bathrooms, closets, shower and tub rooms .Check areas outside the facility .If the resident has not been found within 15 minutes, or after a search of the facility and immediately outside the building the Charge Nurse will notify the police or local law enforcement agency; no… | 2020-09-01 |
| 141 | 141 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 278 | D | 0 | 1 | K1NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 2 residents (#89, #56) of 34 residents reviewed. The findings included: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had no dental problems. Observation with the MDS Coordinator on [DATE] at 2:50 PM revealed the resident lying on the bed. Continued observation revealed the resident had a broken front tooth and stated it happened at the hospital when I was intubated. Interview with the MDS Coordinator on [DATE] at 2:53 PM, in the hallway confirmed the MDS dated [DATE] was not accurate and did not reflect the resident's broken tooth. Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated [DATE] at 1:13 PM revealed Resident unresponsive, VS (vital signs) ,[DATE], resp (respirations) 10, O2 sat (oxygen saturation) room air 57%, 2LM (oxygen at 2 liters per minute) 84%, HR (heart rate) 62. 911 notified and transported to .Hospital ER (emergency room ) for eval (evaluation) and tx (treatment). Medical record review of a Minimum Data Set Death in Facility Tracking record revealed the resident had expired in the facility on [DATE]. Interview on [DATE] at 7:40 AM with the Director of Nursing (DON), in the DON's office revealed the DON had been present on [DATE] when the resident was transferred to the emergency room and had accompanied the resident on the stretcher to the ambulance at the time of transfer. Continued interview confirmed the resident did not expire in the facility and confirmed the Death in Facility Tracking record was not accurate. | 2020-09-01 |
| 142 | 142 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 315 | D | 0 | 1 | K1NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to assess 2 residents (#18, #101) for a bladder retraining program of 4 residents reviewed for urinary incontinence of 34 residents reviewed. The findings included: Review of the facility's policy, Bowel and Bladder Management, undated, revealed The facility will evaluate, monitor and track resident's bowel and bladder patterns and will identify the need for early intervention. Guideline: 1. Facility will evaluate Bowel and Bladder status upon admission, readmission, significant change and quarterly. 2. If a resident is incontinent, a baseline elimination status to assess bowel and bladder patterns will be completed upon admission, readmission, quarterly and with significant change. 3. The interdisciplinary team (IDT) will review bowel and bladder data to determine if retraining is an option or a pattern has been identified . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making and was always incontinent of bladder. Medical record review of a Urinary Continence Evaluation dated 6/16/15 revealed the resident was frequently incontinent. Medical record review revealed no documentation a Urinary Continence Evaluation had been completed since 6/16/15. Interview with Resident #18 on 10/16/16 at 9:00 PM, in the resident's room revealed the resident was aware of the urge to urinate. Interview with the Director of Nursing (DON) on 10/17/16 at 3:50 PM, in the DON's office confirmed the resident had not been assessed for a bladder retraining program since 6/16/15. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record… | 2020-09-01 |
| 143 | 143 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 371 | F | 0 | 1 | K1NZ11 | Based on facility policy review, observation, and interview, the facility failed to properly store frozen food items in 1 of 1 walk-in freezer, failed to properly store dry stock items, failed to discard outdated food in 1 of 2 nourishment refrigerators, failed to properly air dry pans in 8 of 13 pans observed, and failed to ensure kitchen equipment and non-food contact surfaces were clean and maintained in a sanitary manner, affecting 67 of 73 residents. The findings included: Review of the facility policy, Food Storage, dated 1/12/16 revealed .All products should be dated . use by dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer storage .Any expired or outdated food products should be discarded .Frozen foods should be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Label and date all food items .Dry Storage .Any opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated .Continued review of policy revealed .Label and date all storage containers or bins. Keep free of scoops . Review of the facility policy, Pots and Pans, Sanitizing Solution, dated 7/12/16 revealed .Invert items on counter Allow all items to air dry . Review of the facility policy, Mixer, dated 2/1/16 revealed .After each use .Scrub machine (beater shaft, bowl saddle, shell, and base) . Review of the facility policy, Can Opener, dated 9/1/16 revealed .After each meal more frequently if needed .Scrub shank, paying close attention to blade . Review of the facility policy, Dish Machine, dated 2/1/12 revealed .After each meal remove debris and rinse interior of machine. Wipe exterior of machine . Review of the facility policy, Walls and Ceilings, dated 3/14/16 revealed .Vents must be .clean and free of debris . Observation with the Cook on 10/16/16 at 9:50 AM, in the dish room revealed 8 of 13 four inch steam table pans observed had been stored wet. Observation with the Co… | 2020-09-01 |
| 144 | 144 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 441 | D | 0 | 1 | K1NZ11 | Based on facility policy review, observation, and interview the facility failed to ensure infection control during meal distribution on 1 of 3 halls observed. The findings included: Review of the facility policy, Handwashing/Hand Hygiene, dated 8/12 revealed .If hands are not visibly soiled, use an alcohol-based hand rub .for all the following situations .Before and after direct contact with residents .After contact with objects .in the immediate vicinity of the resident . Observation on 10/16/16 at 12:10 PM, on the South hall revealed Certified Nurse Aide (CNA) #4 delivered a meal tray to a room and exited the room without performing hand hygiene. Continued observation revealed CNA #4 retrieved a tray from the tray cart, delivered the tray to another resident, placed the tray on the bedside table, touched her glasses, opened the door to exit the room, and returned the refused tray to the cart. Continued observation revealed CNA #4 went to the kitchen to request peanut butter and jelly sandwiches for the resident, touched the door handle to the kitchen, and delivered the sandwiches to the resident without performing hand hygiene. Interview with CNA #4 on 10/16/16 at 12:19 PM, on the South hall confirmed CNA #4 had washed the hands prior to delivering lunch trays but had failed to perform hand hygiene between each resident and after touching objects while delivering meal trays. Interview with the Director of Nursing (DON) on 10/16/16 at 3:04 PM, in the DON's office confirmed the facility failed to ensure infection control during meal distribution per facility policy. | 2020-09-01 |
| 145 | 145 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 502 | D | 0 | 1 | K1NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure a laboratory test was completed as ordered for 1 resident (#39) of 5 reviewed for unnecessary medications of 34 residents sampled. The findings included: Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone order dated 9/24/16 revealed .CMP (Comprehensive Metabolic Panel-blood test to evaluate organ function) next lab day .Dietary Recommendation . Continued review of the medical record revealed there was no documentation of CMP lab values. Interview with Registered Nurse (RN) #1 on 10/18/16 at 10:03 AM, in the conference room confirmed the CMP for Resident #39 had not been completed as ordered. | 2020-09-01 |
| 146 | 146 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2016-10-18 | 514 | D | 0 | 1 | K1NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain an accurate medical record for 1 (#56) of 34 residents reviewed. The findings included: Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an electronic nursing note dated 7/19/16 at 1:13 PM revealed Resident unresponsive, VS (vital signs) 108/70, resp (respirations)10, O2 sat (oxygen saturation) room air 57%, 2LM (oxygen at 2 liters per minute) 84%, HR (heart rate) 62. 911 notified and transported to .Hospital ER (emergency room ) for eval (evaluation) and tx (treatment). Medical record review of an emergency room report dated 7/19/16 revealed .Initial Greet Date/Time 7/19/16 1115 (11:15 AM) .EMS (emergency medical services) was called after pt (patient) was noted to be unresponsive at SNF (skilled nursing facility) . Interview with the Director of Nursing (DON) on 10/18/16 at 7:40 AM, in the DON's office revealed on 10/19/16 in the morning, exact time unknown, the resident had been transferred to the emergency room and confirmed the medical record was not accurate and did not reflect the correct time the resident was found to be unresponsive. | 2020-09-01 |
| 147 | 147 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-12-13 | 657 | D | 0 | 1 | 84HS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to revise the comprehensive care plan to prevent weight loss for 1 resident (#47) of 21 residents reviewed. The findings included: Review of facility policy titled Care Plans-Comprehensive with an effective date of 10/31/17 revealed, .The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .Care plan interventions are implemented after consideration of the resident's problem areas and their causes .interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals .Care plans are ongoing and revised as information about the resident and the resident's condition change . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #47 had a 13.67% weight loss in 6 months and a 30 day weight loss of 2.44%. Continued review revealed the resident was on isolation for ,[MEDICAL CONDITION].-Difficle the last 2 months with multiple liquid stools contributing to the weight loss. Medical record review of Nutritional Note dated 11/15/17 revealed, .(resident) does not like the texture of pureed foods and does not eat them .likes the sweet items (ice cream and chocolate milk, health shakes; also likes grits) but not much else. Has not been eating mashed potatoes, which she used to like. Recommend additional fluids between meals .recommend sending additional fortified grits during the day . Medical record review of physician's orders [REDACTED].Push oral fluids while awake . Medical record review of the Comprehensive Care Plan dated 5/10/15 and revised 9/22/17 revealed the resident was at risk for nutritional deficits and weight loss due to actual weight loss, and refusal to be weighed at times. Approaches included the following: 5/11/15 Assess need for dietary modification a… | 2020-09-01 |
| 148 | 148 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-12-13 | 757 | E | 0 | 1 | 84HS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review and interview the facility failed to keep 3 residents (#39, #61, #65) free from unnecessary medications for 8 residents reviewed for medications. The findings included: Review of facility policy Medication Administration, dated 5/16, revealed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Medical record review of Transfer Orders dated 7/19/17 revealed .[MEDICATION NAME] (antibiotic) 500mg (milligrams) three times a day; for R (right) hip bone infection, from 06/15 to 07/27/2017 . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 12/12/17 at 3:25 PM in the conference room, after review of the MAR, confirmed the facility failed to stop administration of [MEDICATION NAME] to Resident #39 as ordered, resulting in unnecessary medication administration for the resident. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 250 mg capsule. Give one capsule by mouth twice daily for 14 days . Medical record review of the MAR for (MONTH) and (MONTH) (YEAR) revealed [MEDICATION NAME] was started on 11/22/17 at 9:00 PM and given twice daily at 9:00 AM and 9:00 PM through 12/12/17 for a total of 20 days. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 9:30 AM in the hall at the medication cart near Resident #61's room revealed the 9:00 AM medications had already been given for Resident #61 and [MEDICATI… | 2020-09-01 |
| 149 | 149 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-12-13 | 758 | D | 0 | 1 | 84HS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review and interview, the facility failed to monitor behaviors for 2 residents (#39, #65) of 8 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Review of facility policy [MEDICAL CONDITION] Medication Policy & Procedure, dated 5/9/17, revealed .The facility will make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications in the long term care facility to include regular review for .side effects, risk and/or benefits .Will monitor for the presence of target behaviors on a daily basis . Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 received antianxiety medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 PM - 7 AM shift on 9/6/17 or 9/11/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 10/5/17, 10/14/17 or 10/28/17 and the 7 PM - 7 AM shift on 10/8/17, 10/17/17, 10/21/17, 10/22/17 or 10/26/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 11/1/17, 11/15/17, 11/16/17, 11/21/17 or 11/25/17 and for the 7 PM - 7 AM shift on 11/4/17, 11/9/17, 11/18/17, 11/19/17, 11/22/17, 11/23/17 or 11/30/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 12/1/17, 12/2/17, 12/6/17 or 12/7/17. Medical record review revealed Resid… | 2020-09-01 |
| 150 | 150 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-12-13 | 812 | F | 0 | 1 | 84HS11 | Based on facility policy, cleaning schedule, observation and interview the facility failed to keep 2 of 2 ice machines clean and sanitized. The findings included: Review of the facility policy Ice Machine dated 7/26/17 revealed .Unplug the ice machine. Remove ice. Wash inside of machine with approved detergent and hot water. Then use sanitizing solution and clean cloth to sanitize. Make sure the door liner, door gasket and door frame are free of scale and or mold. Remove rust spots .Frequency: weekly . Review of the cleaning schedule for the ice machine revealed no documentation of cleaning and sanitizing for the weeks of 11/19/17 and 11/26/17. Observation with the Dietary Manager on 12/11/17 at 12:15 PM revealed ice machine #1, located in the dietary department, had a pink line of debris along the hood of the inner ice bin. Observation with the Dietary Manager on 12/11/17 at 12:28 PM of ice machine #2, located on the East Hall Exit, revealed an accumulation of brown debris on the inside of the ice bin and on the inside perimeter. Continued observation revealed dust on the outside perimeter of the bin. Observation with the Dietary Manager on 12/12/17 at 1:44 PM on the East Hall Exit revealed the ice machine #2 had orange, and brownish colored debris on the inner side of the ice bin. Interview with the Dietary Manager on 12/12/17 at 2:03 PM in the conference room confirmed the facility failed to keep the ice machines in a sanitary manner. | 2020-09-01 |
| 151 | 151 | SIGNATURE HEALTHCARE OF MADISON | 445075 | 431 LARKIN SPRING RD | MADISON | TN | 37115 | 2017-12-13 | 880 | D | 0 | 1 | 84HS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview the facility failed to store oxygen tubing in a sanitary manner and failed to date the humidification reservoir for 1 resident (#25) of 4 residents receiving oxygen. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Physician order [REDACTED]. Observation on 12/11/17 at 11:20 AM in Resident #25's room revealed an oxygen concentrator near the head of the bed with the nasal cannula/tubing lying on top of the concentrator and not in a bag. Observation with Licensed Practical Nurse (LPN) #1 on 12/11/17 at 11:27 AM in Resident #25's room revealed an oxygen concentrator near the head of the bed with the oxygen tubing lying on top of the concentrator and not in a bag. Continued observation revealed the humidification reservoir was not dated. Interview with LPN #1 on 12/11/17 at 11:30 AM in the hall near Resident #25's room confirmed the nasal cannula/tubing should be in a dated bag and the humidification reservoir should be dated. Continued interview with the LPN confirmed the facility failed to date and store the nasal canula/tubing in a sanitary manner and failed to date the humidification reservoir. | 2020-09-01 |
| 152 | 152 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2020-02-05 | 812 | F | 0 | 1 | XDXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, and interview, the facility failed to label, date, correctly store resident foods, and discard expired food items, potentially affecting 105 of 105 residents residing in the facility. The findings include: Review of the facility policy titled, Safety & Sanitation Best Practice Guidelines revised ,[DATE] showed .Foods will be stored in their original container or .wrapped tightly in moisture-proof film, film, foil .Clearly labeled with the contents and the use by date . Observation and interview on [DATE] at 10:38 AM, with the Dietary Manager (DM), in the walk-in refrigerator, revealed 65 half pint whole milk cartons with an expiration date of [DATE], and 9 chicken tenders in a plastic container with no open date or expiration date. The DM confirmed the milk was expired, the chicken tenders were unlabeled, and available for resident use. Observation and interview on [DATE] at 10:45 AM, with the DM, in the walk-in freezer revealed a box of 160 sausage links and a 12 pound box of whole hog sausage patties open to air. The DM confirmed the sausage links and sausage patties were stored incorrectly, open to air, and available for resident use. During an interview on [DATE] at 1:15 PM, the Registered Dietician stated all open foods were to be labeled, dated, and expired foods were to be discarded. | 2020-09-01 |
| 153 | 153 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2019-02-27 | 638 | D | 0 | 1 | WOQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, review of the Minimum Data Set (MDS) and interview the facility failed to complete a timely quarterly assessment for 1 resident (#4) of 3 residents reviewed for MDS assessments of 32 sampled residents. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The next non-comprehensive assessment is due within 92 days after the ARD (Assessment Reference Date) of the most recent .assessment . Medical record review for Resident #4 revealed an annual MDS had been completed with an ARD date of 10/9/18. Further review revealed a quarterly MDS assessment had not been completed 1/2019. Interview with the MDS Coordinator, Licensed Practical Nurse on 2/27/19 at 8:45 AM, in the MDS office, confirmed the quarterly assessment had not been completed timely for Resident #4. | 2020-09-01 |
| 154 | 154 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2018-05-09 | 641 | D | 0 | 1 | KRDE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documentation and interview, the facility failed to accurately assess 1 resident (#105) out of 3 residents reviewed for falls of 36 sampled residents. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Post Falls Investigation dated 3/30/18 revealed Resident #105 experienced a fall on 3/29/18 in the resident's room. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed, .resident had any falls since admission . 0 (indicating none) . Interview with the MDS Coordinator on 5/9/18 at 8:30 AM, at the 400 unit nurse's station, confirmed the 4/14/18 MDS for Resident #105 was inaccurate for falls. | 2020-09-01 |
| 155 | 155 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2018-05-09 | 656 | G | 0 | 1 | KRDE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement a comprehensive care plan, for pain management, for 1 Resident (#103) of 12 residents reviewed for pain of 36 residents sampled. The facility's failure to implement the pain management care plan on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to the resident. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE], on Palliative care, (specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump (Patient Controlled [MEDICATION NAME], method of allowing a person in pain to administer their own pain medication) . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION … | 2020-09-01 |
| 156 | 156 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2018-05-09 | 697 | G | 0 | 1 | KRDE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure physician ordered pain medication was available for 1 Resident (#103) of 1 resident on Patient Controlled [MEDICATION NAME] (PCA) pump (method of allowing a person in pain to administer their own pain medication) of 12 residents reviewed for pain. The facility's failure to ensure the pain medication was available on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to Resident #103. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION 0.5ML-1 ML (10MG-20MG) BY MOUTH EVERY HOUR AS NEEDED FOR PAIN . Review of a Nurse's Note dated 5/7/18 at 10:50 AM revealed .Pt (patient) stated this AM that current resting pain level @ (at) 7/10 (7 on a 0-10 scale with 10 being the worst pain) MD (Medica… | 2020-09-01 |
| 157 | 157 | NHC HEALTHCARE, MCMINNVILLE | 445076 | 928 OLD SMITHVILLE RD | MC MINNVILLE | TN | 37110 | 2018-05-09 | 880 | D | 0 | 1 | KRDE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#82) of 1 resident on isolation precautions of 36 sampled residents. The findings included: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].ISOLATION (separation of those known to be infected with a contagious disease to prevent further infections) PT (patient) IN PRIVATE ROOM WITH ALL CARE AND TREATMENT PROVIDED IN ROOM . Medical record review of the resident's care plan dated 4/20/18 revealed .Need for isolation precautions .Maintain isolation per protocol . Observation during the initial tour of Resident #82's room on 5/7/18 at 11:05 AM, in the 100 hallway, revealed no precaution sign on the door and a bedside table, not labeled, in the hallway beside the resident's door. Observation of CNA #3 on 05/07/18 at 12:19 PM, in the100 hallway, obtain a gown and gloves from the bedside table, beside the resident's door, and put on the gown and the gloves to deliver the resident's lunch. Interview with Certified Nursing Assistant (CNA) #2 on 5/8/18 at 10:12 AM, in the rehab dining room, confirmed there should be a sign on the door to see the nurse before entering. Further interview confirmed a precaution sign was not on the door on 5/7/18. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed the facility failed to post an isolation precaution sign on the resident's door to notify staff and visitors of the isolation precautions. | 2020-09-01 |
| 158 | 158 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2020-01-28 | 609 | D | 1 | 0 | GTVW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of Misappropriation of Property to the State Survey Agency timely for 1 resident (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy titled Abuse Protocol, last revised 11/2019, showed .The facility must .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State Law . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 8/15/19 showed .[MEDICATION NAME] ([MEDICATION NAME]) 325 mg (milligrams) 5 mg tablet .every 4 hours .pain . Review of a facility investigation dated 1/1/2020 showed Licensed Practical Nurse (LPN) #6 contacted the facility pharmacy for a refill of Resident #1's [MEDICATION NAME] (pain medication). The pharmacy informed the LPN that the pharmacy had dispensed 1 card containing 30 tablets of the medication to the facility on [DATE] (5 days earlier) for Resident #1. The facility completed an investigation but was unable to locate the missing medication. The resident was refunded the cost of the medication. During an interview on 1/28/2020 at 12:00 PM, the Regional Director of Administration stated .(the facility) was unable to determine what happened to the missing narcotics and that was why (the facility) had not reported the missing narcotics to the local or state agencies . In summary, the facility was unable to locate 30 tablets of [MEDICATION NAME] dispensed by the pharmacy for Resident #1 on 1/1/2020. As of 1/28/2020 the facility had not reported the missing medication to the State Survey Agency (28 days later). | 2020-09-01 |
| 159 | 159 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-04-04 | 657 | D | 1 | 0 | RMJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to update a care plan for 1 of 4 sampled residents (Resident #4) following a fall. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and needed extensive assistance of 2 people with transfers. Review of Falls Log indicated Resident #4 had falls on 1/25/18 and 1/27/18. Observation on 4/2/18 at 9:30 AM revealed Resident #4's bed was in a low position with a fall mat on the floor next to her bed. Review of the Care Plan dated 8/10/16 revealed the plan had not been updated to include a fall mat or placing the bed in a low position. Interview with the Director of Nursing (DON) on 4/4/18 at 12:23 PM, in the DON's office, revealed the care plan should have been updated after the interventions were initiated. | 2020-09-01 |
| 160 | 160 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-04-04 | 659 | G | 1 | 0 | RMJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to follow the plan of care for 1 of 4 sampled residents (Resident #1). The facility's failure to follow the plan of care for transfers resulted in actual harm to Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] for palliative care. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was completely dependent upon staff to conduct all Activities of Daily Living (ADL's) and required maximum assist of 2 staff for transfers. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of the Departmental Notes for Nursing dated 6/6/17 at 12:30 PM revealed the Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed and transferring to a shower chair when the resident slid down the CNA's leg to the floor. The transfer was conducted solely by the Hospice CN[NAME] Interview with the Administrator on 4/11/18 at 1:15 PM, by phone, confirmed the Hospice CNA did not follow the plan of care for a 2-person transfer. | 2020-09-01 |
| 161 | 161 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-04-04 | 689 | G | 1 | 0 | RMJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure 1 of 4 residents (Resident #1) was kept safe from falls by contracted staff caring for residents. The facility's failure to ensure a safe transfer resulted in actual harm to Resident #1. The findings included: Review of the facility's policy titled Fall Risk Evaluation, Prevention, and Intervention reviewed 1/17/17 revealed .VII Procedure .D. When a fall occurs: 1. Assess for injuries, and provide treatment as necessary . The policy did not address not moving the resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for all Activities of Daily Living (ADL's) and required the extensive assistance of 2 people for transfers. Medical record review of a Fall Risk Evaluation dated 3/21/17 revealed the resident was assessed as a high risk for falls. Review of the Departmental Notes for Nursing dated 6/6/17 and timed 12:30 PM revealed the contracted Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed to transfer to a shower chair when the resident slid down the CNA's leg to the floor. The Hospice CNA called for assistance. The resident was examined in the shower room with no apparent injury .no redness or bruising noted . The family and physician were notified. Medical record review of Departmental Notes for Nursing dated 6/6/17 and timed 1:53 PM revealed .Noted right lateral ankle bruising/blueness with [MEDICAL CONDITION] and scratch. Resident frowns when ankle is touched . Continued revi… | 2020-09-01 |
| 162 | 162 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2017-05-03 | 329 | D | 0 | 1 | 5FIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 resident (#16) received a medication in a decreased doseage as ordered by the physician, of 5 residents reviewed for unnecessary medications of 24 residents sampled. The findings included: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of the Pharmacist Medication Review dated 3/8/17 revealed .Change Quetiapine (medication used to treat mental/mood disorders) to 75 mg (milligrams) q AM (every morning) and 75 mg q HS (every night) . Continued medical record review revealed a check mark and the physician's initials that indicated the dosage should be reduced as recommended by the pharmacist. Medical record review of the Physicians Orders dated 3/1/17 through 3/31/17, 4/1/17 through 4/30/17, and 5/1/17 through 5/31/17 revealed .Quetiapine 100 mg 1 tablet PO (by mouth) every evening . Medical record review of the Medication Administration Record [REDACTED].Quetiapine 100 mg 1 tablet PO every evening . was documented as administered through 5/2/17. Interview with the Director of Nursing (DON) on 5/3/17 at 10:42 AM, in the 100 nurse's station, revealed that it would be up to the shift leader to write the order, on a telephone order sheet, after the Medical Doctor (MD) had checked the pharmacy review to make the change.I've got the (MONTH) MAR, and it's not been changed .We missed it . Further interview confirmed the facility failed to follow the facilities process of implementing pharmacy recommendations and failed to ensure Resident #16 received a medication in a decreased doseage. | 2020-09-01 |
| 163 | 163 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2019-06-05 | 640 | C | 0 | 1 | 2MLG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview the facility failed to submit a discharge Minimum Data Set (MDS) discharge assessment timely for one resident (#2) of 1 resident reviewed for discharge MDS assessments of 21 sampled residents. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be submitted .within 14 days after the MDS completion date . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #2 was discharged home on[DATE]. Medical record review of the MDS assessments revealed a discharge assessment was completed on 1/1/19. Interview with Registered Nurse (RN) Information Nurse Consultant on 06/05/19 at 1:50 PM, in the Executive Director's office revealed .discharge assessment was completed but was never transmitted . Continued interview confirmed the facility failed to submit a discharge assessment for the 1/1/19 discharge for Resident #2. | 2020-09-01 |
| 164 | 164 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2019-06-05 | 656 | D | 0 | 1 | 2MLG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (#18) and failed to develop a care plan to include the use of a lap belt for 1 resident (#33) of 21 sampled residents. The findings include: Review of the facility policy Care Plans, revised 11/2018, revealed .Identify needs .Include Physicians .orders Care Plans will be updated as changes occur . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS o… | 2020-09-01 |
| 165 | 165 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2019-06-05 | 689 | D | 0 | 1 | 2MLG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention to prevent accidents for 1 resident (#18) of 3 residents reviewed for falls of 21 sampled residents. The findings include: Review of the facility policy Fall Prevention Program, last revised 3/2017, revealed .Document the fall risk measures in the resident care plan .Assess for safety devices a minimum of once per shift for placement and functioning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordi… | 2020-09-01 |
| 166 | 166 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2019-06-05 | 761 | D | 0 | 1 | 2MLG11 | Based on observation and interview the facility failed to properly label and store medications for 1 of 2 medication carts observed. The findings include: Observation and interview of the station 2 medication cart with Licensed Practical Nurse (LPN) #1 on 6/5/19 at 11:15 AM, on the station 2 hallway, revealed 2 medication cups in the medication cart with opened and unlabeled medications in the cups. Continued observation and interview confirmed LPN #1 had prepared the medications and placed the medications in the cups for administration to residents, and had then left the cart to do another task. Interview with the Executive Director (ED) on 6/5/19 at 12:34 PM, in the ED's office, confirmed the facility failed to properly label and store the medications in the medication cart. | 2020-09-01 |
| 167 | 167 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 641 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (#6) of 26 residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Hospice Certification of Terminal Illness signed by the physician on 1/16/18 revealed .This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course . Medical record review of the quarterly MDS dated [DATE], revealed .section J1400 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) . Continued review of the quarterly MDS dated [DATE] revealed the response to section J1400 was no. Interview with the MDS Coordinator on 6/12/18 at 11:00 AM, at the nursing station, confirmed the MDS dated [DATE] was not accurate and did not reflect the resident had a condition or chronic disease that might result in a life expectancy of less than 6 months. | 2020-09-01 |
| 168 | 168 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 655 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan to address the use of antipsychotic and antianxiety medications for 1 resident (#16) of 5 residents reviewed who were admitted in the past 30 days. The findings included: Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the baseline Care Plan dated 5/31/18 revealed no documentation to address the resident's use of antipsychotic and antianxiety medications. Interview with the Director of Nursing (DON), on 6/13/18 at 9:10 AM, in the DON's office, confirmed a baseline Care Plan had not been developed to address the use of the antipsychotic and antianxiety medications. | 2020-09-01 |
| 169 | 169 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 656 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a care plan to address Diabetes for 1 resident (#37) of 26 residents reviewed. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the current Care Plan dated 5/31/18 revealed no documentation to address the resident's Diabetes with the need for insulin. Interview with the Director of Nursing on 6/12/18 at 2:35 PM, in the Minimum Data Set office, confirmed a Care Plan was not developed to address the resident's Diabetes or insulin. | 2020-09-01 |
| 170 | 170 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 657 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the Care Plan for 1 resident (#31) of 26 resident's reviewed. The findings included: Medical record review revealed Resident #31 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 6/8/18 revealed the resident's family was concerned the resident was sick and had expiratory wheezing. Continued review of the nursing note revealed the physician was notified and orders were received. Medical record review of a chest x-ray dated 6/8/18 revealed Impression: 1. Density in the right infrahilar region which may be due to atelectasis versus developing infiltrate .2. Persistent small left pleural effusion with persistent left basilar atelectasis . Medical record review of a physician's orders [REDACTED]. Medical record review of the Care Plan dated on 5/9/18 revealed no documentation to address the resident's current Pneumonia and treatment. Interview with the Director of Nursing (DON) on 6/12/18 at 5:40 PM, in the Minimum Data Set office confirmed the Care Plan dated 5/9/18 was not revised to address the resident's treatment for [REDACTED]. | 2020-09-01 |
| 171 | 171 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 686 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review,review of the facility skin assessment schedule, interview and observation the facility failed to complete a skin assessment in a timely manner prior to the development of a pressure ulcer for 1 resident (#29) of 2 residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Skin assessment dated [DATE] revealed a picture with bilateral heels circled with a note .red blanchable . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was at risk for developing a pressure ulcer. Continued review of the MDS revealed the resident did not have a pressure ulcer. Medical record review of a Braden scale dated 5/25/18 revealed a score of 14, indicating the resident is at moderate risk for developing a pressure ulcer. Medical record review of a skin assessment dated [DATE] (Friday) revealed a picture of the right heel circled and a note Red heel/blanchable. Medical record review of the facility skin assessment schedule revealed the resident was scheduled to have a weekly skin assessment every Friday. Medical record review of a note on a skin assessment dated [DATE] (Friday), revealed refused skin assessment Medical record review of a nurse's note dated 6/11/18 revealed .Noted during treatment .resident had area of dark/non blanchable skin to Right heel measuring approximately 3.4 x 2 cm (centimeter), middle area more red/purple, surrounding skin more brown in appearance . Area dry and intact . Medical record review of a physician's orders [REDACTED].Float heels while in bed . Interview with the Director of Nursing on 6/12/18 at 1:35 PM, in the MDS office, confirmed if a resident refused a skin assessment the nurse should have returned later to attempt to complete the skin assessment or pass it on for the next shift to complete.… | 2020-09-01 |
| 172 | 172 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2018-06-13 | 880 | D | 0 | 1 | KXBN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the manufacturer's recommendations, medical record review, observation and interview the facility failed to appropriately disinfect a glucose meter (a meter to check blood sugar) after use for 1 resident (#3) of 1 resident observed after use of a glucose meter. The findings included: Review of the manufacturer's instructions for Sani-Cloth, Germicidal Disposable Wipe undated revealed .Areas of Use .Hospital, Healthcare, and Critical Care use .May be used on hard non-porous surfaces of; Bed railings; blood glucose meters .To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry . Review of the facility Adult Sliding Scale Insulin Protocal dated 1/31/18 revealed .Fingerstick Blood Sugar .QID (4 times per day) . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Certified Nursing Assistant (CNA) #1 on 6/12/18 at 11:08 AM, in Resident #3's room revealed the CNA completed a blood glucose check on the resident in his room; brought the glucose meter to a rolling table outside of the resident's room; disinfected the glucose meter for approximately 5 seconds and returned the meter to the case. Interview with CNA #1 on 6/12/16 at 11:15 AM, at the nurse's station confirmed the facility used sani-wipes to disinfect the glucose meter after each use. Continued interview confirmed the CNA was not aware of the manufacturer's instructions for the sani-cloth and failed to appropriately disinfect the glucose meter. Interview with the Director of Nursing on 6/12/18 at 12:50 PM, in the Minimum Data Set (MDS) office confirmed the facility failed to appropriately disinfect the glucose meter and failed to follow the manufacturer's recommendations. | 2020-09-01 |
| 173 | 173 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 241 | E | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure dignity when a foley catheter was not contained in a dignity bag for 1 of 2 (Resident #41) sampled residents with a urinary catheter and 4 of 13 (Certified Nursing Assistant (CNA) # 7, 8, 9 and 13) staff did not request permission to enter resident rooms or referred to residents as boo. The findings included: 1. The facility's Quality of life-Dignity policy documented, .Residents shall be treated with dignity and respect at all times .Residents' private space and property shall be respected at all times .request permission before entering resident's rooms .speak respectfully to resident's .addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number .11. Demeaning practices .that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed . helping the resident to keep urinary catheter bags covered . 2. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].catheter indwelling .provide catheter care . Observation in Resident #41's room on 8/7/17 at 4:02 PM and 8/8/17 at 8:05 AM revealed the urinary catheter bag hanging on the side of the bed without a dignity bag covering it. 3. Observation during a confidential resident interview on 8/8/17 at 8:05 AM in Resident #41's room revealed CNA #8 entered the room without asking permission and stated .ready for your breakfast . CNA #7 then entered Resident #41's room without knocking or requesting permission to enter to deliver a breakfast tray. Observation during a confidential resident interview on 8/8/17 at 11:07 am in Resident #73's room, revealed CNA #8 entered the room without knocking or requesting permission to enter the room and went to the B side of the room to assist the resident with the television. Obser… | 2020-09-01 |
| 174 | 174 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 280 | E | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of Interdisciplinary Care Plan Meeting sign in sheets, medical record review, observation and interview, the facility failed to include Certified Nursing Assistants (CNAs) in Interdisciplinary Care Planning Meetings for 4 of 5 (Resident # 17, 41, 73, and 140) sampled residents, failed to revise the care plan related to dental status for 2 of 5 (Resident #17 and 73) sampled residents with dental concerns, and failed to implement appropriate interventions for falls for 1 of 1(Resident #36) sampled residents reviewed for falls of the 37 residents reviewed during the stage 2 review. The findings included: 1. Review of the facility's Care Plan Development policy documented, .Standard The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's plan of care .the meeting schedule will also be developed to assure a full interdisciplinary teams' presence and involvement in the care plan meeting .Who is responsible for care plan development: .Nursing staff as close to the patient care as possible .Care plans are updated as needed .New problems are handled as they arise, and are (to) be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . 2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Review of the significant change MDS dated [DATE] revealed that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Observation in Resident #17's room on 8/7/17 at 4:00 PM, revealed Resident #17 had missing teeth on the middle upper gums. Interview with Resident #17 on 8/7/17 at 4:05 PM, in his room, Resident #17 was asked about his teeth. Resident #… | 2020-09-01 |
| 175 | 175 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 309 | D | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure timely pain assessments and timely administration of pain medication for 2 of 5 (Resident #41 and 190) residents reviewed for pain and failed to ensure a [MEDICAL TREATMENT] agreement contained the proper components for development and implementation of the resident's [MEDICAL TREATMENT] care plan or the interchange of information that is useful/necessary for the care of the [MEDICAL TREATMENT] resident. The findings included: 1.The facility's PAIN MANAGEMENT policy documented, .Pain management is extremely important to improve the quality of life for the suffering patients .Pain is so important that it can even change an individual's life .the goal of pain management is patient control of interventions for pain relief. Our goal is to promote comfort, independence . 2. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with a readmission on 5/23/16 with [DIAGNOSES REDACTED]. A current physician's orders [REDACTED].BIOFREEZE 4% GEL (MENTHOL) TOPICALLY TO BILATERAL KNEES TWO TIMES A DAY AS NEEDED FOR JOINT PAIN . Review of the (MONTH) (YEAR) Medication, Treatment and Task Administration Record Report (MAR) revealed RN #4 administered [MEDICATION NAME] 20 mg tablet on 8/8/17 at 10:18 AM for pain reported as a 9 with an outcome of 3 documented at 10:57 AM. Interview with Registered Nurse (RN) #4 on 8/8/17 9:58 AM, in the East Hall, RN #4 was asked if there had been any reports of Resident #41 having pain. RN #4 stated, .no not to me . The medication was administered 20 minutes after the surveyor asked RN #4 if Resident #41 had requested any medication for pain. Interview with Resident #41 on 8/8/17 at 5:21 PM, in Resident #41's room, Resident #41 was asked about her complaint of pain that morning and Resident #41 stated, I had a pain pill and then later they rubbed some medicine on them. They're not hurting now … | 2020-09-01 |
| 176 | 176 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 314 | D | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED].Prevention and treatment of [REDACTED].#37) sampled residents reviewed of the 3 residents with pressure ulcers. The findings included: 1. The EPUAP European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (NPUAP), and Pan Pacific Pressure Injury Alliance Prevention and treatment of [REDACTED].INTERNATIONAL NPUAP/EPUAP PRESSURE ULCER CLASSIFICATION SYSTEM .Category/Stage II .Partial Thickness Skin Loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .intact or open serum filled blister .Category/Stage III .Full thickness tissue loss .Subcutaneous fat may be visible .slough may be present .May include undermining and tunneling .(page) 13 .Category/Stage IV: Full Thickness Tissue Loss .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling .Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined .(page) 16 .Conducting Skin and Tissue Assessment 1. In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment .as part of every risk assessment .ongoing based on the clinical setting and the individual's degree of risk .Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals . 3. The facility's Skin Integrity Manual .ASSESSMENT/GUIDELINES/STAGING CRITERIA/PAIN policy documented, .ASSESSMENT . Admission, Readmission, and Return from Transfer Assessments .T… | 2020-09-01 |
| 177 | 177 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 323 | D | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview the facility failed to ensure the environment was free from accident hazards for 1 of 54 (Resident #178) resident rooms when razors were found in the resident room. The findings included: 1. The facility's Hazardous Item Policy documented, .some potential hazardous items include .any item labeled KEEP OUT OF REACH OF CHILDREN. This would include disposable razors . 2. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #178 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe impairment for decision making. The care plan dated 6/8/17 addressed potential for elopement, wandering and rejection of care. 3. Observations on 8/7/17 at 11:15 AM in Resident #178's room revealed one disposable razor in the bathroom and one disposable razor in the nightstand. Observations on 8/07/17 10:45 AM in the 40 hall revealed Resident #178 wandering down the hall. At 12:44 PM Resident #178 was observed on the 40 hall wandering around inside the nurses station. On 8/07/17 at 12:46 PM Resident #178 was observed at the 40 hall medication cart. The resident picked up the water pitcher, placed it back on the medication cart and spilled water on the floor in the process, and then walked into another resident's room. 4. Interview with Registered Nurse (RN) #3 on 8/07/17 at 12:00 PM, in the 40 hall, RN #3 was asked about Resident # 178 and RN #3 stated, Yes, I am familiar .he wanders around frequently . RN #3 was asked if Resident #178 should have razors in his room and RN #3 stated, .I'm not sure . Interview with Licensed Practical Nurse (LPN) #6 on 8/07/17 at 12:31 PM in the dining room, LPN #6 was asked if Resident #178 was confused or was a wanderer. LPN # 6 stated, .he does wander frequently and yes, he is confused. LPN #6 was asked if Resident #178 should have razors s… | 2020-09-01 |
| 178 | 178 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 371 | F | 0 | 1 | BNHK11 | Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by 3 of 9 (Dietary Manager (DM), Dietary Technician (DT) #1, and Regional Administrator (RA) staff in the kitchen not wearing hair covers or beard protectors, carbon build up on the cookware and appliances, 36 wet nested trays, a sugar bin without a lid, and soiled gloves lying on the food preparation table and on a food cart, 1 of 2 (West Hall) nutrition refrigerators had an orange substance covering the bottom of the refrigerator and an unlabeled, undated white Styrofoam cup that contained an unknown brown liquid. The facility had a census of 89 with 84 of those receiving a meal tray from the kitchen on 8/7/17 and 87 of those receiving a meal tray from the kitchen on 8/8/17 and 8/9/17. The findings included: 1. The facility's PERSONAL HYGIENE policy documented, .Dietary partners shall wear hair restraints such as hats, hair coverings or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens . Observations in the Kitchen on 8/7/17 at 10:40 AM, revealed the DM and the RA with no hair cover. Observations in the Kitchen on 8/7/17 at 11:40 AM, and on 8/8/17 at 1:21 PM, revealed DT #1 without a beard cover. Interview with the Director of Dietary on 8/8/17 at 1:21 PM, in the Kitchen, the Director of Dietary was asked what she expected when Kitchen staff or other facility staff enters the kitchen. The Director of Dietary stated, Anybody that comes in the door to the Kitchen has to have a hair net. The Director of Dietary confirmed that beards should be covered. 2. The facility's MANUAL WAREWASHING policy documented, .Air-dry all items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observations in the Kitchen, on 8/7/17 at 10:55 AM, revealed 36 trays wet-nested in the dishwasher area. Interview with the DM on 8/7/17 at 10:58 AM, near the d… | 2020-09-01 |
| 179 | 179 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 411 | D | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure dental services were provided for 1 of 3 (Resident #17) sampled residents reviewed of the 37 residents reviewed in the stage 2 sample for dental. The findings included: 1. The facility's DENTAL SERVICES policy documented, .All patients should have provisions for routine and emergency care by a dentist .The center will assist (if necessary) the patient in making an appointment and arranging transportation . 2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. The significant change MDS dated [DATE] documented that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Observations in Resident #17's room on 8/7/17 at 4:00 PM, revealed Resident #17 had missing teeth on the middle upper gums. Interview with Resident #17 on 8/7/17 at 4:05 PM, in his room, Resident #17 was asked about his teeth. Resident stated, I have some teeth that hurt, I want to be seen by a dentist . Interview with Licensed Practical Nurse (LPN #5) on 8/11/17 at 10:24 AM, at the East Hall nurses station, LPN #5 was asked if she had assessed Resident #17's dental status. LPN #5 stated, Yes. LPN #5 was asked if she had referred him for dental services. LPN #5 stated, I did refer him to the Social Services Director because he sets up the dental appointments. Interview with the Social Services Director on 8/11/17 at 10:11 AM, in the Social Services office, the Social Services Director was asked if Resident #17 should have received dental services. The Social Services Director stated, Yes, Ma'am. | 2020-09-01 |
| 180 | 180 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 431 | D | 0 | 1 | BNHK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview the facility failed to ensure medications were properly labeled and stored for 1 of 54 (room [ROOM NUMBER]) rooms. The findings included: 1. The facility's Hazardous Item Policy documented, .some potential hazardous items include .any item labeled KEEP OUT OF REACH OF CHILDREN . 2. Observations on 8/7/17 at 11:15 AM, in room [ROOM NUMBER], revealed one tube of zinc oxide and one tube of hemorrhoid medication not labeled with a resident's name and unsecured in the bathroom. Observations on 8/07/17 10:45 AM in the 40 hall revealed Resident #178 wandering down the hall. At 12:44 PM Resident #178 was observed on the 40 hall wandering around inside the nurses station. On 8/07/17 at 12:46 PM Resident #178 was observed at the 40 hall medication cart. The resident picked up the water pitcher, placed it back on the medication cart and spilled water on the floor in the process, and then walked into another resident's room. 3. Interview with the Director of Nursing (DON) on 8/11/17 at 5:21 PM, in the Conference Room, the DON was asked if it was acceptable for residents to have medications stored in their bathroom. The DON stated, .No it is not . | 2020-09-01 |
| 181 | 181 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 441 | D | 0 | 1 | BNHK11 | Based on policy review, observation and interview the facility failed to ensure staff practiced proper infection control practices during a bed bath for 1 of 1 (Resident #3) sampled residents observed during a bed bath. The findings included: The facility's Bath, Bed policy documented, .to clean, refresh and soothe patient .Wash your hands .Put on gloves .Wash face and ears, rinse and dry .Wash neck, arms, chest and abdomen, rinse and dry .Wash thighs, legs, and feet, rinse and dry .Wash back, buttocks and genitalia, rinse and dry (wash female genitalia from front to back to avoid cross-contamination with feces) .Remove gloves .Wash hands . Observations in Resident #3's room on 8/10/17 at 8:55 AM, revealed Certified Nursing Assistant (CNA) #12 performing a bed bath for Resident #3. Washcloth #1 was used for Resident #3's face, both arms and 1 swipe across her abdomen. Washcloth #2 was used to swipe the top of the right leg and the top of the left leg; while Resident #3 held her legs up CNA #12 swiped the abdomen again then used the same cloth for the right side of Resident #3's back and her bottom which had stool present. CNA #12 left the dirty wash cloth under the resident's bottom and turned the resident to her opposite side. CNA #12 used washcloth #3 for the other half of the resident's back and bottom. CNA #12 removed her gloves and failed to perform hand hygiene. CNA #12 used 3 washcloths for the entire bath and did not perform hand hygiene during the bed bath. Interview with the Director of Nursing (DON) on 8/11/17 at 11:33 AM, in the Conference Room, the DON was asked about the procedure and use of only 3 wash cloths for a bed bath. The DON read this surveyor's notes and stated, I would expect a different washcloth to be used .going from clean to dirty . | 2020-09-01 |
| 182 | 182 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 497 | E | 0 | 1 | BNHK11 | Based on review of Certified Nursing Assistant (CNA) inservice hours and interview the facility failed to ensure the minimum 12 hours of inservice was completed for 5 of 23 (CNA #3, 6, 7, 8, and 10) CNA's employed for the (YEAR) calendar year. The findings included: 1. The CNA list of inservices provided by the facility revealed the following CNA's did not have the required 12 hours of inservice: a. CNA #6 Hire date 8/10/11 completed 9 hours of inservice. b. CNA #10 hire date 11/4/13 completed 9.75 hours of inservice. c. CNA #3 hire date 9/3/2007 completed 11.75 hours of inservice. d. CNA #8 hire date 5/2/2007 completed 10.75 hours of inservice. e CNA #7 hire date 11/2/1987 completed 6.5 hours of inservice. Interview with the Administrator on 8/11/17 at 2:20 PM, in the Conference Room, the Administrator confirmed the list of CNA inservice hours provided was for the CNA's employed the entire year of (YEAR). | 2020-09-01 |
| 183 | 183 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2017-08-11 | 520 | D | 0 | 1 | BNHK11 | Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement an effective ongoing quality program that identified developed, implemented and monitored appropriate plans of action for care plans and kitchen sanitation. The findings included: 1. The QAA Committee failed to ensure that services were provided in accordance with each resident's written plan of care related to revising care plans and implementing appropriate interventions for fall prevention and implementing a plan to ensure interdisciplinary team meetings included members of the direct care staff. The deficient practice of F-280 is a repeat deficiency and was cited on the recertification survey on 10/30/13 and 5/13/15. Refer to F280 2. The QAA Committee failed to ensure food was served under sanitary conditions related to lack of hair restraints, wet nesting dishes, cleaning ovens and equipment, pans with carbon buildup, used gloves lying on food preparation area and cleanliness of nourishment refrigerators. The deficient practice of F371 is a repeat deficient practice for failure to store, prepare and distribute food under sanitary conditions. The facility was cited F371 on the recertification survey on 10/30/13, 5/13/15 and on 5/19/16. Refer to F371 3. Interview with the QAA Coordinator on 8/11/17 at 6:17 PM in the Health Information Manager office, the QAA Coordinator did not identify care planning and kitchen sanitation as an ongoing concern that the QAA Committee had identified. | 2020-09-01 |
| 184 | 184 | NHC HEALTHCARE, SPRINGFIELD | 445088 | 608 8TH AVE EAST | SPRINGFIELD | TN | 37172 | 2018-08-22 | 695 | D | 0 | 1 | ITOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide oxygen therapy and bilevel positive airway pressure/continuous positive airway pressure ([MEDICAL CONDITION]/[MEDICAL CONDITION]) as ordered for 1 of 5 (Resident #27) sampled residents reviewed for respiratory services. The findings included: 1. The facility's undated MEDICATIONS, ADMINISTERING policy documented, .will give medications only per physician's orders [REDACTED]. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #27 was cognitively intact and received oxygen therapy. The physician's orders [REDACTED].OXYGEN .3 LITERS/MINUTE VIA NASAL CANNULA . The Treatment Administration Record Report for (MONTH) (YEAR) documented, .OXYGEN 3 LITERS/MINUTE VIA NASAL CANNULA .7am-7pm .7pm-7am .3L (liters) . Observations in Resident #27's room on 8/20/18 at 10:45 AM and 2:30 PM, 8/21/18 at 9:50 AM, 10:30 AM, and 4:20 PM, and 8/22/18 at 7:30 AM, revealed Resident #27 was receiving oxygen via nasal cannula at a flow rate of 1.5 liters/minute. Interview with the Director of Nursing (DON) on 8/22/18 at 11:45 AM, in Resident #27's room, the DON was asked what the oxygen flow rate should be set on the concentrator. The DON stated, Whatever is on the physician's orders [REDACTED].>2. The facility's .Non-invasive Positive Pressure Ventilation Continuous Positive Airway Pressure Bilevel Costive Airway Pressure policy with a revision date of 1/05 documented, .Non-invasive Positive Pressure Ventilation (NIPPV) is used to manage spontaneously breathing patients with severe hypoxemia caused by .sleep apnea .NIPPV included Continuous Positive Airway Pressure ([MEDICAL CONDITION]) and Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) . The physician's orders [REDACTED].AT BEDTIME . The Treatment Administration Record (TAR) Rep… | 2020-09-01 |
| 185 | 185 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 584 | D | 0 | 1 | SLUH11 | Based on observation and interview, the facility failed to provide a comfortable and homelike environment when staff and family members were knocking loudly on the kitchen door on 2 of 6 days (1/28/2020 and 1/29/2020) of the survey. The findings include: Observation in the 100 Hall on 1/28/2020 at 8:30 AM, 9:00 AM, 9:17 AM, 9:25 AM, 9:50 AM, 1:30 PM, 3:13 PM, 4:15 PM, 4:25 PM and 6:40 PM, showed several staff members knocking loudly on the kitchen doors. Observation in the 100 Hall on 1/28/2020 at 1:27 PM, showed a family member knocking loudly on the kitchen doors. Dietary Aide #1 opened the kitchen door and the family member asked why was the kitchen door locked. Dietary Aide #1 stated, Because state is here . Observation in the 100 Hall on 1/29/2020 at 8:17 AM, showed several staff members knocking loudly on the kitchen doors. During an interview on 1/28/2020 at 9:56 AM, Resident #82 stated, They just started banging on the door while state is here .they lock it when state's (state is) in the building . During an interview on 1/30/2020 at 11:33 AM, Resident #15 stated, They lock the door when state is here . During an interview on 1/29/20 at 12:15 PM, the Regional Registered Dietitian confirmed that the staff and family members should not be knocking loudly on the kitchen doors. During an interview on 2/1/2020 at 11:26 AM, the Director of Nursing (DON) confirmed that she would not expect the staff members to be knocking loudly on the kitchen doors. | 2020-09-01 |
| 186 | 186 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 637 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to initiate a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were ordered for 1 of 29 sampled residents (Resident #28) reviewed. The findings include: Review of the medical record, showed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (Named Hospice) PHYSICIAN ORDERS [REDACTED].Admit to hospice services (sign for with) primary DX (diagnosis): Bladder CA (Cancer) . Medical record review, showed there was not a Significant Change MDS completed after Resident #28's admission to hospice services. The facility failed to complete a significant change MDS within 14 days of Resident #28's admission to hospice services. During an Interview on 1/30/2020 at 3:35 PM, the MDS Coordinator confirmed that a significant change MDS related to hospice was not completed for Resident #28. | 2020-09-01 |
| 187 | 187 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 641 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an assessment was accurate related to [MEDICAL TREATMENT] and hospice for 2 of 29 sampled residents (Resident #28 and #55) reviewed. The findings include: 1. Review of the medical record, showed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (Named Hospice) PHYSICIAN ORDERS [REDACTED].Admit to hospice services (sign for with) primary DX (diagnosis): Bladder CA (Cancer) . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 was not coded for receiving hospice services. Review of the Physician order [REDACTED].Hospice to evaluate and treat as indicated per (Named Hospice) . During an interview on 1/30/2020 at 3:35 PM, the MDS Coordinator confirmed that the quarterly MDS dated [DATE] should have been coded for hospice services. 2. Review of the medical record, showed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].[MEDICAL TREATMENT] evey Tuesday, Thursday, and Saturday . Review of the quarterly MDS assessment dated [DATE], showed Resident #55 was not coded as receiving [MEDICAL TREATMENT]. During an interview on 1/30/2020 at 1:48 PM, the MDS Coordinator confirmed that the quarterly MDS dated [DATE] should have been coded for [MEDICAL TREATMENT]. | 2020-09-01 |
| 188 | 188 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 656 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a comprehensive plan of care was developed for a [DIAGNOSES REDACTED].#65) reviewed. The findings include: Review of the medical record, showed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised 1/28/2020, showed there was not a comprehensive Care Plan to reflect a [DIAGNOSES REDACTED]. During an interview on 2/1/2020 at 10:15 AM, Patient Coordinator #1 confirmed that Resident #65 did not have a Care Plan for the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 189 | 189 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 689 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents' rooms were free from accident hazards when equipment was stored unsafely and a cord was hanging freely from the ceiling in 2 of 59 rooms (Resident #18's room and Resident #31's room). The findings include: Review of the facility's policy titled, DEPARTMENTAL FIRE PR[NAME]EDURES NURSING, revised 8/2018, showed that you should not place equipment into occupied patient rooms. 1. During an interview on 1/28/2020 at 4:52 PM, Life Enrichment Coordinator #1 confirmed that Life Enrichment Coordinator #2 pushed the meal cart into Resident #18's room during the fire drill. During an interview on 1/28/2020 at 7:09 PM, the Administrator confirmed that equipment should not be stored in occupied resident rooms. During an interview on 2/1/2020 at 11:33 AM, the Director of Nursing (DON) confirmed that equipment or meal carts should not have been stored in the resident's room. 2. Review of the medical record, showed Resident #31 had a [DIAGNOSES REDACTED]. Observation in the resident's room on 1/27/2020 at 10:30 AM, 1:20 PM, 4:55 PM, and 1/28/2020 at 7:30 AM, 12:15 PM, and 12:48 PM, showed a long black cord hanging freely from the ceiling of Resident #31's room. During an interview on 1/28/2020 at 5:45 PM, Licensed Practical Nurse (LPN) #1 stated, .I have been off 4 days .it wasn't there the last day I worked . During an interview on 1/28/2020 at 5:55 PM, the Maintenance Director confirmed that the black cord hanging from the ceiling could be an accident hazard. During an interview on 1/28/2020 at 6:00 PM, the Administrator stated, .I did not know this (cord) was hanging here . | 2020-09-01 |
| 190 | 190 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 690 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure that an indwelling urinary catheter was secured for 1 of 2 sampled residents (Resident #77) reviewed. The findings include: The facility's policy titled, CATHETER CARE, INDWELLING (MALE AND FEMALE), dated 2005, showed to secure the catheter tubing at the insertion site. Review of the medical record showed, Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed that Resident #77 had an indwelling catheter. Review of the Care Plan dated 4/25/2019, showed no indication that Resident #77 refused to have his indwelling urinary catheter secured. Review of the physician's orders [REDACTED].#77 had an indwelling urinary catheter. Observation in the resident's room on 1/29/2020 at 9:52 AM, showed Resident #77's indwelling catheter tubing was unsecure and hanging freely. During an interview on 1/29/2020 at 10:50 AM, Patient Care Coordinator #1 stated that the resident would refuse to have his catheter secured. During an interview on 1/29/2020 at 2:29 PM, the Certified Nursing Assistant (CNA) Instructor stated, .anchor the tubing . During an interview on 1/29/2020 at 3:34 PM, the Director of Nursing (DON) stated that the resident would refuse to have his indwelling catheter secured. Medical record review showed, there was no documentation that Resident #77 would refuse to have his indwelling urinary catheter secured. | 2020-09-01 |
| 191 | 191 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 842 | D | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to maintain complete and accurate weights for 1 of 12 sampled residents (Resident #18) reviewed. The findings include: Review of the facility's undated policy titled, Weights, showed that if a discrepancy is noted with the weights the patient should be re-weighed using the same type of scale. Review of the medical record, showed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Variance Report showed the following weights: 7/3/2019 - 121 lbs (pounds) 7/4/2019 - 173 lbs (52 lbs difference in 1 day) 9/12/2019 - 156 lbs 9/13/2019 - 145 lbs (11 lbs difference in 1 day) 9/19/2019 - 156 lbs 9/20/2019 - 145 lbs (11 lbs difference in 1 day) 11/20/2019 - 151 lbs 11/30/2019 - 127 lbs (24 lbs difference in 10 days) 12/1/2019 - 136 lbs 12/30/2019 - 127 lbs 1/1/2020 - 140 lbs (13 lbs difference in 2 days) 1/3/2020 - 127 lbs (13 lbs difference in 2 days) 1/3/2020 -140 lbs (13 lbs difference the same day) During an interview on 1/30/2020 at 12:50 PM, the Regional Registered Dietician (RD) confirmed that Resident #18's weights were incorrect. During an interview on 2/1/2020 at 11:35 AM, the Director of Nursing (DON) confirmed that Residents 18's weights were inaccurate. | 2020-09-01 |
| 192 | 192 | NHC HEALTHCARE, LEWISBURG | 445094 | 1653 MOORESVILLE HIGHWAY | LEWISBURG | TN | 37091 | 2020-02-01 | 880 | E | 0 | 1 | SLUH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed in 2 of 3 isolation rooms (Resident #55 and #73's rooms), failed to maintain infection control practices for respiratory therapy masks and oxygen tubing for 6 of 10 sampled residents (Resident #74, #31, #39, #28, #61, and #33) receiving respiratory services, failed to ensure linens were removed properly from a resident's room (Resident #77), failed to ensure an indwelling catheter bag and tubing were kept off of the floor for 1 of 2 sampled residents (Resident #77) reviewed with an indwelling urinary catheter, and 2 of 4 Certified Nursing Assistants (CNA #1 and #3) failed to perform hand hygiene and proper catheter care for 1 of 2 sampled residents (Resident #55) reviewed during indwelling catheter care. The findings include: Review of the facility's policy titled, STANDARD PRECAUTIONS, revised 1/10/2020, showed that appropriate Contact Precautions sign should be placed on the residents' room doors. 1. Observation outside of the resident's room on 1/27/2020 at 10:45 AM, showed no signage posted on Resident #55's door to alert the staff and visitors of isolation precautions. Observation outside of the resident's room on 1/27/2020 at 11:20 AM and 12:28 PM, showed no signage posted on Resident #73's door to alert the staff and visitors of isolation precautions. During an interview on 1/30/2020 at 7:34 AM, the Director of Nursing (DON) confirmed that the isolation rooms should have signage on the door to alert the staff and visitors of isolation precautions. Review of the facility's policy titled, DEPARTMENTAL PR[NAME]EDURES, revised 10/1/2008, showed that respiratory equipment at the beside should be covered with a plastic bag when not in use. 2. Observation in the resident's room on 1/27/2020 at 9:30 AM, 1/28/2020 at 10:09 AM, and 1/29 2020 at 8:30 AM, showed Resident #74's Bilevel Positive Airwa… | 2020-09-01 |
| 193 | 193 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2019-06-03 | 609 | D | 1 | 0 | 10P111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse to the state survey agency timely for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed 6. Reporting Policy .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of a facility investigation dated 5/27/19 at 8:45 AM revealed Resident #1 reported an allegation of inappropriate contact to a Certified Occupational Therapy Assistant (COTA). Continued review revealed the COTA immediately reported the incident to the Administrator, Director of Nursing (DON) and the physician. Further review revealed Resident #1 alleged the incident occurred the morning of 5/25/19, but did not report it to the facility until 5/27/19. Continued review revealed Resident #1 was examined by the physician on 5/27/19 at 12:30 PM and no obvious physical injuries or conclusive findings were discovered. Further review revealed the resident was sent to a local hospital on [DATE] at 2:23 PM for further examination by a Sexual Assault Nurse Examiner (SANE) nurse and no clinical findings of an assault were discovered. Continued review revealed the f… | 2020-09-01 |
| 194 | 194 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2017-10-18 | 431 | E | 0 | 1 | DDHK11 | Based on review of facility policy, observation, and interview, the facility failed to discard expired medications in 1 of 4 medication refrigerators, and to secure controlled medications under a double lock system for 2 of 3 medication refrigerators of 4 medication refrigerators reviewed. The findings included: Review of the facility policy Medication Storage in the Facility dated 6/2016 revealed .medications .are stored safely .following manufacture's recommendations .outdated .are immediately removed from inventory, disposed of according to procedures for medication disposal . Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 6/2016 revealed .medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances .subject to special .requirements .kept under double lock . Observation and interview with Registered Nurse (RN) #1 on 10/18/17 at 10:40 AM, in the 3rd floor Medication Storage Room, revealed inside the medication refrigerator, 1 premixed intravenous (IV) solution of Vancomycin (antibiotic) 750 milligrams (mg) in 250 milliliters (ml) 0.9 percent Normal Saline solution dated 10/11/17. Continued observation and interview confirmed the expired IV antibiotic solution was available for use. Observation and interview with the RN/Resident Care Coordinator (RN/RCC) on 10/18/17 at 10:55 AM, in the Front Nursing Station, with no door to separate the nursing station from the hallway, revealed a locked medication refrigerator. Further observation and interview with the RN/RCC of the medication refrigerator, confirmed 2 vials of Lorazepam (antianxiety medication) 2 mg/ml with no double lock system to secure the controlled medication. Observation and interview with the RN/RCC on 10/18/17 at 11:10 AM, in the West Nursing Station, with no door to separate the nursing station from the hallway, revealed a locked medication refrigerator. Further observation and interview of the medication refrigerator … | 2020-09-01 |
| 195 | 195 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 641 | D | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 resident (#9) of 36 sampled residents. The findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Medication Order dated 12/20/17 revealed a physician's orders [REDACTED]. Medical record review of the Nurse's Notes dated 9/1/18 documented, .placed wanderguard to (R) (right) ankle . Medical record review of the Quarterly ((MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status score of 3, indicating the resident was severely cognitively impaired. Further review revealed Resident #9 required limited assist of one staff member for locomotion on the unit and was not assessed as having as wandering behavior. Medical record review of the Recreation Quarterly Progress Note dated 9/4/18 revealed, .(Resident #9) continues his same daily routine .with much confusion and ambulates around his rooma nd (and) the facility as he likes through the day Pt (patient) .walks around the facility and has to be redirected many times as he will wonder (wander) in and out of other rooms in the facility . Medical record review of Resident #9's Comprehensive Care Plan dated 4/4/18 and updated 9/12/18 revealed .Resident has wandering tendencies . Observation and interview with Certified Nursing Assistant #1 on 12/03/18 at 12:29 PM, in the 2nd floor dining room, revealed Resident #9 confused and wandering. Interview confirmed .He does this all day, he wanders talking . Interview with Licensed Practical Nurse #1 on 12/04/18 at 3:51 PM, on the east hall, revealed Resident #9 wanders daily about the facility. Further interview revealed .He has wandered since admission; it's something he's always done . Interview with MDS Coordinator #1 on 12/05/18 at 10:28 AM, in the MDS office, revealed Resident #9 wanders and was not coded on the MDS… | 2020-09-01 |
| 196 | 196 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 644 | E | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to resubmit a PASARR Level 1 (Pre Admission Screening and Resident Review that determines whether or not an individual who has an active [DIAGNOSES REDACTED].#56 and #59) of 4 residents reviewed for PASARR level 2 (The results of this evaluation result in a determination of need, determination of appropriate setting and a set of recommendations for service to inform the individual's plan of care) of 36 residents reviewed. The finding include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated 6/11/14 revealed Resident #56 did not have a [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Progress Note dated 10/19/18 revealed .Pt (patient) seen for the management of dementia, anxiety, and depression . Medical record review of Resident #56's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #56 had current [DIAGNOSES REDACTED]. Medical record review of Resident #56's Comprehensive Care Plan updated 11/6/18 revealed, .Side effects, potential for: [MEDICATION NAME] (an antidepressant medication), [MEDICATION NAME] (a mood stabilization medication) .Dx (diagnosis) depression, anxiety, behaviors .becomes agitated .Mental Health Consult & Tx (treatment) . Medical record review of the current physician's orders [REDACTED].[MEDICATION NAME] HCL (a medication for depression) 30 mg (milligrams) . with order dated 1/19/18 and .[MEDICATION NAME] Acid (a medication for mood stabilization) 250 mg/5ml (milliliters) . with order dated 3/8/18. Further review revealed, .Psychiatric services to evaluate and treat as needed . with order dated 5/18/17. Medical record review of the Diagnostic Problem List dated 12/4/18 revealed, .Anxiety Disorder .Start date 6/12/14 .End date 9/22/17 .[MEDICAL CONDITION] .Start date 12/22/14 .End date 2/20/18 .Generalized Anxiety … | 2020-09-01 |
| 197 | 197 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 656 | D | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop and implement a comprehensive care plan to include care of a concussion after a fall for 1 resident (#100) of 2 residents reviewed for falls of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Continued review revealed Resident #100 returned to theER on [DATE] at 12:10 PM, after complaints of increased drowsiness s/p (status [REDACTED]. Medical record review of the Comprehensive Care Plan revealed no care plan on the care and management of concussions for Resident #100. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed she failed to develop a care plan for the care of Resident #100's concussion. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to develop and implement a care plan for the care of a concussion following a fall for Resident #100. | 2020-09-01 |
| 198 | 198 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 657 | D | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise a care plan for fall risk and skin integrity following a fall with a laceration for 1 resident (#100) of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100 on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Baseline Care Plan, undated, for Resident #100 revealed care areas for Fall Risk and Skin/Wound. Further review revealed the Fall Risk Care Plan was updated on 11/24/18 with CNA (Certified Nursing Assistant) instructed to stay with pt (patient) while toileting. Continued review revealed no revision to the Skin/Wound Care Plan and no documentation of the scalp laceration. Medical record review of the Complete Patient Care Plan, dated 11/28/18 revealed care plans for Falls and At Risk for Alteration in Skin Integrity with no revision or documentation of care or treatment of [REDACTED]. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed it was her respo… | 2020-09-01 |
| 199 | 199 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 684 | D | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of medical records, observation, and interview, the facility failed to follow hospital discharge instructions following a fall for 1 (#100) resident of 2 residents reviewed for falls of 36 residents sampled. The findings include: Review of the facility policy Transfer Documentation, revised 1/2017, revealed .Responsibilities upon patient's return to the center .physician's orders should accompany the patient from the hospital. admission orders [REDACTED].Begin a new Medication Record using the new physician orders received upon return . Review of the facility policy Return From Transfer/Medical Appointment with Specialist, undated, revealed .Any patient that is transferred to the ER (emergency room ) .the facility will resume previous in-house orders and include any changes from the ER evaluation . Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Notes revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the ER at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Daily Skilled Nurse's Note for Resident #100, dated 11/24/18 at 7:26 AM, revealed .returned from h… | 2020-09-01 |
| 200 | 200 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2018-12-05 | 695 | D | 0 | 1 | 5IOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of nursing standards of care, medical record review, observation, and interview, the facility failed to provide respiratory care to address 1 resident's (#105) decline in respiratory status of 8 residents reviewed for respiratory care of 36 residents reviewed. The findings include: Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition, Lippincott publisher 2010 revealed, Assessing for Heart Failure - Be alert for the following signs and symptoms: GENERAL - Fatigue .Dependent [MEDICAL CONDITION], Weight Gain .Respiratory - Dyspnea on exertion . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed, A&O x3 (alert and orient to person, place and time) .Respirations even/unlabored with diminished bases (less lungs sounds heard in lower lungs) .Expressed need for therapy before returning home. Medical record review of a Nurse Practitioner's progress note dated 11/26/18 revealed, Pt (patient) seen today following admission .pt reports doing okay, just with little energy .called back to her room later this afternoon because her O2 (oxygen) saturation dropped to 86% on room air (normal O2 saturation value 94-99%) 1) [MEDICAL CONDITIONS] with exertional dyspnea (shortness of breath) will give additional 40 mg (milligrams) [MEDICATION NAME] (diuretic) .now .3) [MEDICAL CONDITION] with exacerbation .Schedule [MEDICATION NAME] QID (respiratory nebulizer treatments 4 times a day) .Aggressive [MEDICAL CONDITION] toilet (medical and nursing measures to address lung function). Encourage pt to splint and cough. Check CXR (chest X-ray) 2 views now . Medical record review of the Nurse Practitioner's progress noted dated 11/27/18 revealed, .9) Volume overload (too much retained fluid) - SP (status [REDACTED]. Medical record review of the Daily Skilled Nurses Notes revealed from 1… | 2020-09-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );