rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
329,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-10-25,253,B,0,1,QBNE11,"Based on observation and interview, the facility failed to maintain the walls in good repair in 4 of 19 rooms on 1 of 4 floors. The findings included: Observation of room 505 on 10/23/17 at 2:15 PM revealed there were several areas with white mudding (compound to smooth drywall) on the painted green wall at the head of the bed. Observation and interview with the Maintenance Director on 10/24/17 at 3:50 PM of the wall in room 505 revealed there were 9 areas of mudding on the wall, with the largest area measuring approximately 36 inches in length. Continued interview confirmed the wall was in need of repair/painting. Interview with the facility's painter with the Maintenance Director present on 10/24/17 at 4:00 PM, in the hallway revealed the wall had been mudded 6 months ago and confirmed the green wall had not been repainted after the mudding. Observation and interview with the Maintenance Director on 10/25/17 at 9:30 AM of the walls in rooms 503, 513, and 519, confirmed the walls had areas of sheetrock showing and were in need of repair.",2020-09-01
352,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,161,B,0,1,CP8M11,"Based on facility records review and interview, the facility failed to provide a Surety Bond to cover the residents' personal funds account. The findings included: Review of the daily ledger balance summary for the residents' personal funds dated 12/1/16 through 12/31/16 revealed the following balances: 1) 12/2/16 with a balance of $42,126.24 2) 12/5/16 with a balance of $41,265.53 3) 12/6/16 with a balance of $41,665.53 4) 12/7/16 with a balance of $19,884.93 5) 12/8/16 with a balance of $19,849.93 Review of a facility letter from the insurance company dated 12/5/16 revealed a bond amount of $18,000.00. Interview with the Administrator on 2/1/17 at 7:45 AM in the conference room, confirmed the Surety Bond amount was $18,000.00 and the resident trust balance had been more than $18,000.00 on 5 occasions in (MONTH) (YEAR).",2020-09-01
5678,LAURELWOOD HEALTHCARE CENTER,445413,200 BIRCH ST,JACKSON,TN,38301,2015-08-12,156,B,0,1,Z3X911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #46 and 64) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #46 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 06.08.15 and on 06.09.15 . The form was signed but not dated by the Patient / Representative. Interview with the Social Worker on 3/12/15 at 2:30 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #46 was not dated by the Patient/Representative. 2. Review of the Notice of Medicare Non-Coverage for Resident #64 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 07.7.15 . The Patient/Representative signed and dated the form on 7/14/15. Interview with the Social Worker on 3/12/15 at 2:35 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #64 was not signed and dated by the Patient / Representative prior to the effective date of non-coverage.",2019-01-01
10442,"VANCO MANOR NURSING AND REHABILITATION CENTER, INC",445460,813 S DICKERSON RD,GOODLETTSVILLE,TN,37072,2013-04-19,425,B,0,1,VETJ11,"Based on review of facility documentation, review of facility policy, and interview the facility failed to provide pharmacy services to four residents of thirty-three residents reviewed. The findings included: Review of facility documentation Borrowed Medication Log revealed four narcotics had been borrowed from four residents to administer to other residents April 2-8, 2013. Review of facility policy Borrowing of Meds dated February 2013, revealed .The practice must be limited to the exceptional occasion when a medication is needed and cannot be obtained from the pharmacy or the backup pharmacy . Interview with the Director of Nursing (DON), on April 18, 2013, at 9:13 a.m., in the DON Office, confirmed the backup pharmacy does not provide narcotics to the facility. Continued interview confirmed the facility borrowed four narcotics from residents to administer to other residents.",2016-07-01
10587,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2013-02-12,371,B,0,1,DN0M11,"Based on observation and interview the facility failed to provide sanitary storage of food in one of two resident nourishment refrigerators. The findings included: Observation of the south hall resident nourishment refrigerator on February 11, 2013, at 2:50 p.m., revealed: 1. a one gallon container of fruit punch one-third full opened and not labeled 2. a half pint container of whole milk, half full, opened and not labeled 3. two one liter containers of bottled water one-third full, opened and not labeled 4. a ten ounce container of orange juice half full, opened and not labeled Interview with the Director of Nursing and the Licensed Dietitian, at that time, confirmed the beverages should be dated when opened and labeled with the resident's name.",2016-06-01
13030,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2011-05-25,372,B,0,1,V14O11,"Based on observation and interview the facility failed ensure garbage and refuse were properly disposed of. The findings included: Observation of the facility's dumpsters on May 23, 2011, at 12:30 p.m., with the Dietary Manager (DM), revealed the dumpster area with scattered refuse including: three disposable latex gloves, six plastic straws, three plastic cups, two candy wrappers, two used sweetener packets, and plastic utensils (a fork and knife) on the ground surrounding the dumpster. Interview with the DM, at the time of the observation, confirmed the dumpster area was not clean and well maintained.",2015-05-01
13159,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2015-02-11,371,B,0,1,PJXT11,"Based on observation and interview, the facility failed to store food in a sanitary manner to prevent cross-contamination between resident food items and non-food items for three of seven refrigerator/freezers designated for resident snacks, on two of four units observed. The findings included: Observation with Licensed Practical Nurse (LPN) #4 on February 10, 2015, at 12:55 p.m., of the station 1 nourishment refrigerator/freezer, revealed individual servings of ice cream for resident use stored in the freezer. Continued observation revealed three ice packs had been stored on the door rack of the freezer (one freezer gel pack and two solid ice packs). Observation with LPN #3 on February 10, 2015, at 1:00 p.m., of the station 4 nourishment refrigerator/freezer located in the Kitchen/Ice Machine room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one solid ice pack had been stored on the door rack of the freezer. Observation with LPN #3 on February 10, 2015, at 1:05 p.m., of the station 4 nourishment refrigerator/freezer located in the Med (medication) Prep (preparation) Room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one gel freezer pack had been stored in the freezer next to the resident's ice cream. Interview with LPN #2 on February 10, 2015, at 2:15 p.m., at nurse's station 4, confirmed the ice packs were not to be stored with the food items. Interview with the Registered Dietician on February 10, 2015, at 4:15 p.m., in the Parkwood Dining Room, confirmed non-food items were not to be stored with the resident's snacks.",2015-04-01
9,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2020-02-20,574,C,0,1,UNET11,"Based on facility policy review, admission packet review, interview, and observation, the facility failed to support each resident's rights by ensuring the required State Survey Agency's contact information was made available for 3 of 3 residents (Resident #1, Resident #2, and Resident #16). Interviews obtained during the resident group meeting revealed the residents had not been given information on how to file a complaint with the State Survey Agency. This failure had the potential to affect all 43 residents of the facility who may want to exercise their right to file a complaint directly with the State Survey Agency. Findings include: Review of the facility's policy titled, Patient Rights and Responsibilities-Siskin West Subacute, undated, revealed the residents had the right to .contact the Tennessee Department of Health directly at (telephone number) to lodge any concerns you may have about your care. Review of the facility's policy titled, Resident Rights, undated, located in the facility's admission packet provided during the entrance conference, revealed at the time of admission, and periodically through their stay, the facility would inform each resident, orally and in writing, of their rights. The policy stated the resident had the right to voice grievances to the facility, or other agency or entity that hears grievances, without discrimination or reprisa,l and without fear of discrimination or reprisal. The policy also stated the resident had the right to be afforded the opportunity to contact these agencies. The policy stated the resident had the right to immediate access to any of the following: any representative of the Secretary of the U.S. Department of Health and Human Services, any representative of the State, the resident's individual physician, the State's long-term care ombudsman, and the agency responsible for the protection of, and advocacy system for, mentally or developmentally disabled individuals. Review of an untitled and undated form, located in the Admission Packet provided by the facility during the entrance conference, revealed residents could report a complaint or grievance to the Administrator, Director of Nursing, and/or Director of Quality/Grievance Officer. Residents could also report a complaint or grievance directly to the Ombudsman, CMS (Centers for Medicare & Medicaid Services), or to the State of Tennessee Department of Health. There was no contact information for the State of Tennessee Department of Health on the form. Interviews with Resident #1, Resident #2, and Resident #16 on 2/19/2020 at 10:39 AM, during the group meeting in the third-floor chapel, revealed the residents had not been given information on how to contact the State Survey Agency to formally complain about the care they received. Resident #16, who was the Resident Counsel President, stated, it would be good to know or have just in case. Observation and interview with the Administrator on 2/20/2020 at 1:00 PM, in the entry way of the first floor, revealed information about how to contact the State Survey Agency was hanging on the wall in a picture frame. Interview with the Administrator revealed the area between the parking garage and the lobby of the first-floor was not a common area where residents of the facility frequented, but visitors did. Interview with Certified Nurse Aide (CNA) #7 on 2/20/2020 at 1:29 PM, at the second-floor nurses' station, revealed to her knowledge, there was no information posted about how to contact the State Survey Agency. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 1:33 PM, at the second-floor nurses' station, revealed to her knowledge, there was no posting or information about how to contact the State Survey Agency. Interview with the Administrator on 2/20/2020 at 1:41 PM, at the second-floor nurses' station, revealed she had updated the admission packet today to include how to contact the State Survey Agency. Interview with LPN #8 on 2/20/2020 at 1:45 PM, at the third-floor nurses' station, revealed to her knowledge, there were no postings with information about the State Survey Agency. The LPN stated if a resident needed the State Survey Agency's number, they could always ask someone at the nurses' station and they would get the number for them.",2020-09-01
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
261,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,569,C,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, review of the facility's documentation of the Notification Summary Report (resident trust funds/Resident Statement), and interview, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for 2 discharged residents (#402 and #403) of 313 Patient Trust Funds reviewed. The findings include: Review of the facility policy, Patient Trust, Subject: Refunds, revised date ,[DATE], revealed .Timing (Schedule) the funds should be refunded within 30 days of death or discharge . Medical record review revealed Resident #402 was admitted to the facility on [DATE]. Continued review revealed the Resident was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #402 had a balance of $1719.70. Medical record review revealed Resident #403 was admitted to the facility on [DATE]. Continued review revealed Resident #403 was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #403 had a balance of $1686.57. Interview with the Trust Bookkeeper on [DATE] at 8:40 AM, in the business office, confirmed the facility had not refunded the Resident's Trust Fund accounts for Residents #402 and #403. Continued interview confirmed the facility had not refunded the accounts within the required time frame.",2020-09-01
301,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,814,C,0,1,SM1F11,"Based on observation and interview, the facility failed to maintain a lid on 1 of 1 dumpster to prevent vermin from entering the dumpster. The findings include: Observation and interview on 10/8/18 at 9:55 AM, with the Dietary Manager outside of the facility at the dumpster site, revealed the garbage dumpster did not have a lid to prevent possible vermin from entering the dumpster. Interview with the Dietary Manager confirmed the dumpster did not have a lid in place.",2020-09-01
357,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2018-02-28,881,C,0,1,4KZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Center Statement, review of the Antibiotic Stewardship Notebook and Infection Control Records, and interview, the facility failed to implement an Antibiotic Stewardship program for 98 of 98 residents in the facility. The findings included: Review of the facility Center Statement: Antibiotic Stewardship undated revealed .( Name of facility) is committed to establish and implement practices to maximize treatment of [REDACTED]. Review of the Antibiotic Stewardship Notebook and Infection Control Records with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the Assistant Director of Nursing office, revealed no system was in place to monitor antibiotic usage in the facility for residents with infections. Interview with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the ADON's office, confirmed .I don't surveillance antibiotics .There is no written antibiotic protocol .I review labs and cultures at the end of the month .We have no antibiotic policy just a mission statement . Continued interview confirmed she was not aware of the specific infections and the antibiotic medications prescribed in the facility. Further interview confirmed the facility had not developed, promoted or implemented a system to monitor use of antibiotics in the facility.",2020-09-01
379,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,582,C,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 2 of 3 residents (Resident #20 and Resident #33) with the Advanced Beneficiary Notice, Center for Medicare and Medicaid Services (CMS)- when they ended therapy services and remained in the facility for long-term care services. This failure left residents without information related to the cost of therapy services if they desired to continue them in the facility and did not allow for them to have informed choice. Findings include: Resident #20 was admitted on [DATE] for a Medicare A stay. He had [DIAGNOSES REDACTED]. He received physical therapy, occupational therapy, and speech language therapy. The Social Service Director (SSD) issued the Notice of Medicare Non-Coverage (CMS- ) on 10/2/2019 informing him therapy services would end on 10/7/2019. The SSD did not issue the CMS- Advance Beneficiary Notice to the resident. The resident remained in the facility for long-term care and had Medicare benefit days remaining. Resident #33 was re-admitted on [DATE] after a hospital stay. His admitting [DIAGNOSES REDACTED].#33 received speech language therapy upon returning to the facility. The SSD issued the CMS- informing him that therapy would be ending on 12/20/2019. The CMS- was not issued to the resident or Family Member #33 indicating why the Medicare therapy services would no longer be covered and the cost of the therapy services, and the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Interview with the SSD on 1/14/2020 at 12:01 PM revealed she was responsible for issuing all beneficiary notices. She stated she did not issue the CMS- to any residents remaining in the facility that had Medicare days remaining. She further stated the interdisciplinary team reviewed all Medicare residents and determined as a team that the individual no longer met Medicare requirements. She stated she was unaware that residents coming off Medicare and remaining in the facility as long-term care with benefit days remaining were supposed to receive the CMS- . Interview with Family Member #33 on 1/14/2020 at 12:35 PM revealed that they were not provided the CMS- . Interview with Resident #20 on 1/15/2020 at 3:11 PM revealed he had not been issued the CMS- detailing why his Medicare therapy was ending or the cost of the services.",2020-09-01
556,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,803,C,0,1,X9ZT11,"Based on review of nutritional guidelines, menu review, and interview, the facility menu failed to meet nutritionally adequate standards for 3 of 4 weeks in the menu cycle. Findings include: Review of the Nutritional Guidelines and Menu Checklist for Residential and Nursing Home, 2014, revealed 5 or more servings of fruit and vegetables should be served daily. Further review revealed food high in fat should be used sparingly. Review of the 4 week cycle menu revealed the following: Week 1 Sunday Supper was Hamburger on Bun, French Fries, Fudge Round, and Lettuce/[NAME]to/Onion. Week 1 Monday Lunch was Tuna Salad on Bun, Tator Tots, Soup, Donuts. Week 1 Tuesday Lunch was Corn Dog Nuggets, French Fries, Cookie. Week 1 Friday Lunch was Grilled Chicken Breast, Macaroni Salad, Waffle Fries. Supper was Pizza, Tossed Salad (no tomato), Fruit. Week 1 Saturday Lunch was Hot Dog on Bun, Chili, Saltine Crackers, Tator Tots, Donut. Week 3 Sunday Lunch was Fish Sandwich, French Fries, Macaroni Salad, Cookie. Week 3 Wednesday Lunch Corn Dog, Tator Tots, Baked Beans, Cookie. Supper was Chicken Nuggets, French Fries, Mixed Vegetables, Honey Bun. Week 3 Thursday Lunch was[NAME]Wagon Burger, French Fries, Lettuce/[NAME]to/Onion, Fig Newton. Week 4 Sunday Lunch was Fish Sandwich, French Fries, Fruit Cup, Fig Newton. Week 4 Tuesday Lunch was Cheese Pizza, Tossed Salad, (no tomato) Cookie. Supper was Corn Dog Nuggets, French Fries, Baked Beans, Fruit Parfait. Week 4 Thursday Supper was Hamburger on Bun, Fries, Lettuce/[NAME]to/Onion, Donuts. Week 4 Saturday Supper was Corn Dog, Tator Tots, Fruit Salad, Italian Ice. Review of the menu cycle revealed the menu failed to have 5 or more servings of fruit and vegetables daily. Interview with 13 Resident Council members on 4/30/18 at 2:00 PM in the Dining Room revealed the residents complained of meals being served cold on a daily basis. Further interview revealed the residents also complained of fried foods and sandwiches frequently served. Interview with the Dietary Manager (DM) on 5/1/18 at 1:35 PM in the dietary department revealed the DM determined what food needed to be ordered, the food order went to the corporate office and the corporate office determined what to actually order. Further interview revealed .Sometimes get a totally different product and not match what (DM) requested . Further interview revealed .a Resident had requested a chuck wagon sandwich (breaded pork patti), and I requested the product called 'chuck wagon' but what we got looked like a breaded hot dog, it was really red on the inside and looked just like a hot dog insides . Further interview revealed one meat product, once it was cut up, looked unappealing, the DM checked the ingredients and noted meat by-products and red dye and would not serve the product. Further interview revealed .We have fresh fruit in-house, and we have canned and frozen vegetables . Further interview revealed the .Resident Council meeting stated they wanted more food like what had 'outside' before they came here, fun food like corn dogs, hot dogs, hamburgers, chicken nuggets, fries, so Registered Dietitian #2 then adjusted menu . Interview with Registered Dietitian #1 on 5/2/18 at 11:15 AM in the Conference Room confirmed the menu was not based on nutritional standard regarding fruit and vegetables and fried foods. Confirmed menu looks like .kids menu items . and .a lot of carbohydrates .",2020-09-01
582,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,661,C,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge for 3 residents (#92, #94, #248) of 6 residents reviewed for transfer/discharge requirements. The findings include: Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the facility' discharge transfer/discharge documentation dated 5/10/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 4/19/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #248 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 1/24/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Interview with the Minimum Data Set Coordinator on 6/25/19 at 12:20 PM, in the conference room, confirmed the transfer/discharge form was the only documentation the facility completed with the Physician's signature.",2020-09-01
611,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,356,C,1,0,DC3711,"> Based on observation and interview, the facility failed to post the nurse staffing information for 3 of 6 days. The findings included: Observation on 5/8/17 at 8:25 AM revealed the nurse staffing information form posted by the main entrance lobby area was dated 5/4/17, Thursday. Interview with the Main Entrance Receptionist on 5/8/17 at 8:45 AM by the posted nurse staffing information form in the main entrance lobby area confirmed the form was dated 5/4/17. Further interview revealed the Receptionist posted the nursing staff information form Monday through Friday. Further interview revealed the Receptionist did not receive the nurse staffing information forms in order to post them on Friday. Interview with the Staff Development Director (SDD) on 5/9/17 at 10:45 AM by the posted nurse staffing information in the main entrance area confirmed the SDD was responsible to fill out the nurse staffing information forms. Further interview revealed the SDD was to give the nurse staffing information forms to the receptionist on Thursday to post for Friday, Saturday and Sunday. Further interview confirmed the SDD failed to provide the staffing information forms to the receptionist for 5/5/17, 5/6/17, and 5/7/17 and the information was not posted.",2020-09-01
702,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,732,C,0,1,TUZL11,"Based on observation and interview, the facility failed to update the daily posted staffing and census on 6/8/19 and 6/9/19. The findings include: Observation on 6/10/19 at 8:39 AM on the main hallway wall revealed the posted staffing and census was dated 6/7/19. Interview with the Director Of Nursing on 6/13/19 at 5:29 PM in the conference room confirmed .we usually have the weekend Admission Nurse to post the daily staffing and census. She took the weekend off and we got somebody to cover the admission part but forgot to update them on that part (posting the daily staffing and census sheet daily) .",2020-09-01
706,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,732,C,0,1,ITMM11,"Based on observation and interview, the facility failed to update the posted staffing and census on 6/23/18 and 6/24/18. Findings included: Observation on 6/25/18 at 8:08 AM on the main hallway wall revealed the posted staffing and census was dated 6/22/18. Interview with the Administrator on 6/25/18 at 1:30 PM in the private dining room confirmed the facility failed to update the posted staffing and census for 6/23/18 and 6/24/18.",2020-09-01
853,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,732,C,1,0,RPNN11,"> Based on observation and interview, the facility failed to post the current daily staffing for 1 of 5 days of the survey. The findings included: Observation on 12/12/17 at 7:15 AM in the main lobby and hall area, with various informational postings for families and residents, revealed the posted staffing and census form was dated 11/20/17. Interview with Licensed Practical Nurse #11 on 12/12/17 at 7:30 AM in the conference room, after reviewing the posted staffing form, confirmed the posted staffing and census was dated 11/20/17. Interview with the Director of Nursing at 8:35 AM in the conference room confirmed the posted staffing form dated 11/20/17 was not current.",2020-09-01
965,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,577,C,0,1,HIXZ11,"Based on observation and interview, the facility failed to provide the most recent survey results for resident and public review in the facility's survey notebook. The findings include: Observation on 1/14/19 at 11:45 AM, at the facility entrance, revealed a survey notebook on a table. Continued obsevation revealed the contents of the notebook did not contain the survey results from the last recertification survey from 2/6/18. Interview with the Administrator on 1/14/19 at 2:30 PM, in the Administrator's office confirmed the survey results from 2/6/18 had not been placed in the notebook.",2020-09-01
1235,LIFE CARE CENTER OF RED BANK,445240,1020 RUNYAN DR,CHATTANOOGA,TN,37405,2017-05-17,356,C,0,1,VSOY11,"Based on facility documentation review and interview the facility failed to retain accurately posted staffing data. The findings included: Review of the Staffing Posted Data from 11/17/16-5/17/17 revealed the following: A) The Facility's name was not documented on the staffing posted data forms from 6/2016-5/16/17. B) Incomplete documentation on staffing data posted forms including the date, the total and actual hours worked by Registered Nurses, License Practical Nurses, Certified Nursing Assistants and the resident census on multiple forms. C) Missing staffing posted data forms for multiple dates. Interview with the Administrator on 5/17/17 at 5:43 PM, in the Administrator's Office confirmed the facility failed to document the facility's name on all staffing posted data forms from 6/2016 to 5/17/17. Continued interview confirmed the facility failed to complete documentation on forms including the date, total and actual hours worked by Registered Nurses, Licensed Nursing Staff, Certified Nursing Assistants, and the resident census for multiple dates. Further interview confirmed the facility failed to retain staffing data forms for multiple dates.",2020-09-01
1372,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2018-12-12,732,C,0,1,IZRR11,"Based on policy review, observation and interview, the facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care each shift for 3 of 3 days during the survey. The findings include: Review of an undated facility policy, Posting Daily Nurse Staffing, revealed .This center will post daily nurse staffing per CMS (Centers for Medicare and Medicaid Services) and the State of Tennessee requirements . Observation on 12/10/18, 12/11/18 and 12/12/18 of the posted daily staffing sheets posted in front of the Director of Nurse's (DON) office revealed no posting of the total number of staff responsible for resident care. Interview with the DON on 12/12/18 at 7:33 AM in her office confirmed she did not post the number of staff on the daily posting sheet. She stated I don't post the numbers, just the staff.",2020-09-01
1381,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2017-03-08,356,C,0,1,FXLB11,"Based on observation and interview, the facility failed to post the nurse staffing correctly for one of three days observed. The findings included: Observation and interview with the Director of Nursing on 3/6/17 at 8:50 AM, in the hall, confirmed the Posted Nurse staffing did not include the number of staff working and the census for 3/6/17.",2020-09-01
1384,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2018-05-03,577,C,0,1,2DL711,"Based on observation and interview, the facility failed to ensure the most recent survey results were readily accessible for all 92 residents residing in the facility. The findings included: Observation in the facility lobby on 5/1/18 revealed a white binder with survey results from the facility's last annual survey on 3/8/17. Continued observation revealed no documentation of the facility's most recent survey results from a complaint investigation conducted on 9/5/17. Interview with the Administrator on 5/3/18 at 7:58 PM, in the Administrator's office, confirmed the facility had not included the most recent survey results in their annual survey binder located in the facility's lobby, .it was an oversight .",2020-09-01
1436,BRIARCLIFF HEALTH CARE CENTER,445260,100 ELMHURST DR,OAK RIDGE,TN,37830,2017-01-11,356,C,0,1,TU9H11,"Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 1/9/17 at 8:35 AM, in the facility main hallway, revealed the nurse staffing sheet posted was dated 1/7/17 and 01/8/17. Interview with Registered Nurse #1 on 1/9/17 at 8:50 AM, in the facility main hallway, confirmed the nurse staffing sheet posted was not for the current date.",2020-09-01
1490,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-01-10,838,C,0,1,Y2ZQ11,"Based on review of the Facility Assessment Tool and interview the facility failed to conduct a facility-wide assessment. The findings included: Review of the Facility Assessment Tool, dated 8/18/17 revealed no documentation a facility assessment had been conducted. Interview with the facility Administrator on 1/10/18 at 1:29 PM in the conference room confirmed the facility had failed to conduct a facility assessment.",2020-09-01
1492,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-01-10,881,C,0,1,Y2ZQ11,"Based on facility policy review and interview the facility failed to implement an Antibiotic Stewardship Program. The findings included: Review of the facility policy, Antibiotic Stewardship Program undated revealed .It is the policy .to implement and maintain an Antibiotic Stewardship Program . Interview with the Director of Nursing (DON) on 1/9/18 at 2:40 PM, in the DON's office confirmed the facility had failed to implement an Antibiotic Stewardship Program.",2020-09-01
1568,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2017-02-01,159,C,0,1,OV2211,"Based on review of Resident trust fund (personal fund) account records and interview, the facility failed to provide quarterly Resident personal fund statements for 52 residents of 52 residents or their legal representative with personal funds accounts for the 10/2016 through 12/2016 quarter. The findings included: Review of the quarterly Personal Funds accounts statements dated 10/2016-12/2016 revealed 52 residents had a Personal Funds account with the facility. Continued review revealed the quarterly statements accounted for the residents' Personal Funds account money. Further review revealed Resident #13 was one of the 52 residents who had a Personal Funds account with the facility. Telephone interview with Resident #13's legal representative on 1/30/17 at 3:48 PM revealed he had never received a quarterly statement for the Resident's Personal Funds account. Interview with the Director of Human Resources (DHR) on 2/1/17 at 9:05 AM in the front office revealed the facility had only supplied personal funds statements upon request. Further interview with the DHR confirmed the facility failed to provide residents or their legal representative with quarterly Personal Funds account statements.",2020-09-01
1570,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2017-02-01,254,C,0,1,OV2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain bed and bath linens in good condition for resident use. The findings included: Observation on 1/30/17 at 11:07 AM on the B Hall, room [ROOM NUMBER], restroom revealed a frayed washcloth with holes hanging on the towel bar. Observation on 1/30/17 at 11:53 AM on the C Hall, room [ROOM NUMBER], revealed a blanket on the bed in use by the resident with torn, frayed edges along two sides. Observation on 1/30/17 at 3:38 PM on the D Hall, room [ROOM NUMBER]B, revealed a blanket on the bed in use by the resident with frayed edges on the hem of the blanket. Observation on 1/30/17 at 4:12 PM on the B Hall, room [ROOM NUMBER] restroom revealed a towel with holes hanging on the towel bar. Observations on 1/31/17 beginning at 8:53 AM revealed the D Hall linen cart contained frayed, torn towels. A second linen cart on D hall located by the shower room contained 1 blanket with frayed, torn edges and towels with frayed edges. The B Hall linen cart contained thin wash cloths and thin towels. Observations on 2/1/17 beginning at 10:45 AM while conducting a walk through tour of the facility with the Housekeeping Supervisor and the Maintenance Supervisor to observe surveyor team concerns revealed: 1.Hall B, room [ROOM NUMBER], towel hanging on towel rack that was worn thin with frayed edges and holes; 2.Linen Cart on B hall with washcloths, towels, and blankets that were worn thin and frayed; 3.Linen Cart on D hall with washcloths and towels that were worn thin and frayed. Interview with the Housekeeping Supervisor on 2/1/17 at 11:30 AM near the A/B nurses station confirmed the facility had failed to maintain bed and bath linens in good condition and available for resident use.",2020-09-01
1770,HOLSTON MANOR,445295,3641 MEMORIAL BLVD,KINGSPORT,TN,37664,2018-11-28,620,C,0,1,S68D11,"Based on review of a facility admission agreement, facility policy review, and interview, the facility failed to establish an admission policy which did not request or require residents or potential residents to waive potential facility liability for losses of personal property for all 126 residents currently residing in the facility. The findings include: Review of the facility's Admission Agreement, undated, revealed .Personal Property and Valuables .Resident or Resident Representative agrees to be responsible for all valuables .personal property in his or her possession while the Resident is at the Facility. The facility shall not be responsible for lost, damaged or stolen items . Review of a facility policy, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised (MONTH) (YEAR), revealed .Residents are not required or requested to waive facility liability for loss or misappropriation of personal property . Interview with the Administrator on 11/28/18 at 10:23 AM, in the Administrator's Office, confirmed the facility does not have to reimburse for missing/lost items. Further interview revealed the admission agreement signed by the resident or the resident's Power of Attorney (POA) upon admission stated the facility is not responsible for lost or missing personal property. Continued interview confirmed all residents or POAs are required to sign the admission agreement upon admission.",2020-09-01
1835,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2019-02-07,732,C,0,1,OXBH11,"Based on facility policy review, observation and interview, the facility failed to update the daily posted staffing from 1/29/19 though 2/4/19 (6 days). The findings include: Review of the facility policy, Posting of Nurse Staffing, dated 6/28/18 revealed .On a daily basis, at the beginning of the shift, the facility must have posted or available for review the following data .Facility name .Current date .Resident Census .The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered Nurses, Licensed Practical Nurses or licensed vocational nurses .Certified nurse aide . Observation on 2/4/19 at 9:01 AM revealed .Daily Staffing Form . was dated 1/29/19 (6 days). Interview with Certified Nursing Assistant (CNA) #1 who also works in central supply on 2/6/19 at 2:21 PM in the conference room revealed (CNA #1) was responsible for updating and posting the staffing form Monday through Friday. Further interview revealed .the MOD (Manager on Duty) was supposed to post the daily staffing form on the weekends and when (CNA #1) went on leave . Further interview revealed when asked if (CNA #1) updated the daily staffing form for 2/4/19 she stated .I did not do it that day, I teched (worked on the floor) on that day and (MONTH) 1st I stocked supplies . Interview with the Interim Director of Nursing on 2/6/19 at 5:52 PM in her office confirmed .I expect the daily staffing post to be posted no later than 9 AM . Continued interview confirmed the Daily Staffing form was not posted from 1/29/19 through 2/4/19 (6 days).",2020-09-01
2068,WESTMORELAND CARE & REHAB CTR,445342,1559 NEW HIGHWAY 52,WESTMORELAND,TN,37186,2017-04-20,356,C,0,1,1EAK11,"Based on observation and interview, the facility failed to post staffing requirements for 79 of 79 days reviewed. The findings included: Observations on 4/17/17 to 4/20/17 revealed the Daily Staffing Form posted on the large bulletin board in the hallway near the commons area. Continued observation revealed the actual hours worked were not documented on any of the forms for these dates. Further review of the Daily Staffing Forms for February, March, and (MONTH) (YEAR) revealed the actual hours worked were not documented on any of the forms. Interview with the Administrator and the Director of Nursing on 4/20/17 at 8:34 AM, in the Administrator's office, when shown the daily staffing forms and the actual hours worked column was not completed, confirmed the facility had failed to complete the hours worked because they did not realize it was required.",2020-09-01
2096,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2018-08-23,623,C,0,1,ZDQV11,"Based on review of the Emergency Transfer from Facility forms and interview, the facility failed to send the Ombudsman a notice of transfer or discharges for the months of April, May, and (MONTH) of (YEAR) for a total of 45 of 45 residents reviewed for emergency transfers. The findings include: Review of the Emergency Transfer from Facility forms dated 4/1/18 to 6/30/18 revealed 45 residents had emergency discharges from 4/1/18 - 6/30/18. Telephone interview with the Volunteer Assistant Ombudsman confirmed the Ombudsman had not been notified of acute emergency transfers from 4/1/18 to 6/30/18. Interview with the Business Office Manager on 8/22/18 at 10:03 AM, in the Business Office, confirmed emergency transfers from the facility reports had not been sent to the ombudsman from 4/1/18 to 6/30/18.",2020-09-01
2281,PIGEON FORGE CARE & REHAB CENTER,445382,415 COLE DRIVE,PIGEON FORGE,TN,37863,2017-08-16,356,C,0,1,VBZ511,"Based on review of the facility's Daily Staffing Form, observation, and interview, the facility failed to post daily staffing information. The findings included: Review of the facility's Daily Staffing Form revealed .Nursing Staffing Directly Responsible for Resident Care .Daily Posting of this information is required for nursing homes participating in Medicare and Medicaid. Observation on 8/14/17 at 8:30 AM, revealed the staffing information posted was dated 8/12/17. Observation and interview with the Administrator, in the facility lobby, on 8/14/17 at 9:00 AM, confirmed the staffing information had not been posted since 8/12/17.",2020-09-01
2294,PIGEON FORGE CARE & REHAB CENTER,445382,415 COLE DRIVE,PIGEON FORGE,TN,37863,2018-09-19,842,C,0,1,GSVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 Resident (#58) of 5 residents reviewed for unnecessary medications of 47 residents sampled. The findings included: Review of facility policy Medication Administration dated 5/2016, revealed .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .the space provided on the front of the MAR (medication administration record) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 9/1/18 to 9/30/18 revealed .Aripiprazole (antipsychotic medication) 10 mg (milligrams) .1 tablet orally daily . Medical record review of a MAR indicated [REDACTED]. Interview with the Director of Nursing on 9/19/18 at 7:05 PM, in the conference room, confirmed the facility failed to document why resident #58 missed 3 doses of Aripiprazole and the facility failed to follow facility policy.",2020-09-01
2361,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2017-03-29,372,C,0,1,3KL011,"Based on facility policy review, observation, and interview, the facility failed to dispose of garbage and refuse properly in 1 of 1 observations made of the outside dumpster area. The findings included: Review of a facility policy, Garbage and Trashcans revised 2/24/16 revealed .The dumpster area must be free of debris on the ground and the lid must be closed . Observation with the Dietary Manager (DM) on 3/27/17 at 10:25 AM, of the outside dumpster area, revealed two garbage bags exposed from under the lid of the dumpster with the lid closed down on the garbage bags. Continued observation revealed the followig items on the ground beside the dumpster: a). five disposable gloves. b). multiple pieces of paper. c). several slices of tomato, onion slices, and unidentifiable food particles. Interview with DM on 3/27/17 at 10:30 AM, outside at the dumpster area, confirmed the facility failed to properly maintain the dumpster area in a clean and sanitary manner.",2020-09-01
2365,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-05-24,577,C,0,1,63GM11,"Based on observation and interview, the facility failed to ensure the most recent survey results were readily accessible for all 96 residents residing in the facility. The findings included: Observation in the facility lobby on 5/22/18, at 11:00 AM, revealed a white binder with survey results from the facility's last annual survey on 3/27/17. Continued observation revealed no documentation of the facility's most recent survey results which had been conducted on 2/21/18. Interview with the Administrator on 5/22/18, at 11:05 AM, in the admissions office confirmed the facility did not include the most recent survey results in their survey results binder stating .It was my understanding it (the binder) was only to include the last annual survey .",2020-09-01
2588,MCKENZIE HEALTH CARE CENTER,445429,175 HOSPITAL DRIVE,MC KENZIE,TN,38201,2017-11-15,170,C,0,1,FZEQ11,"Based on resident rights and interview, the facility failed to ensure the residents were allowed to receive mail on Saturday. This practice could have affected all of the residents in the building receiving mail. The facility reported a census of 82. The findings included: The facility's Welcome Booklet documented, .Mail will be delivered to you each day . Interview with Resident #26 on 11/13/17 at 3:53 PM, in the resident's room, Resident #26 stated, .no mail on Saturday for the past 2 years .Resident Council has discussed mail not being delivered on Saturday .it would be nice to receive mail on Saturday . Interview with the Activities Director on 11/13/15 at 4:49 PM, in her office, the Activities Director was asked if residents received mail on Saturdays. The Activities Director stated, .they receive mail on Monday through Friday .the business office is closed on Saturday . Interview on 11/13/17 at 11:11 AM, outside the activity room, the Administrator was asked if the residents receive mail on Saturday. The Administrator stated .They were told and were ok not getting mail on Saturday .",2020-09-01
2718,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2019-07-24,732,C,0,1,YH9R11,"Based on policy review, document review, and interview, the facility failed to complete daily staff postings for 105 of 105 days reviewed. The findings include: The facility's Nurse Staffing Posting Information policy dated 11/17 and revised 11/18 documented, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and to make staffing information readily available .The total number and the actual hours worked .per shift .Registered Nurses .Licensed Practical Nurses .Certified Nurse Aides .must include all nursing staff paid by the facility . Review of the facility's Daily Nurse Staffing forms dated 4/9/19 through 7/22/19 revealed there was no documentation of the total number and and actual hours staff worked each shift. Interview with the Staffing Coordinator on 7/24/19 at 3:41 PM, in the Staffing Office, the Staffing Coordinator confirmed the hours for licensed staff were not on the daily staff postings. The Staffing Coordinator was asked if she had included the total hours worked on the Daily Nurse Staffing form. The Staffing Coordinator stated, No, Ma'am .",2020-09-01
2736,MISSION CONVALESCENT HOME,445447,118 GLASS ST,JACKSON,TN,38301,2017-11-21,156,C,0,1,CXGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #16, 28, and 44) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's Form Instructions for the Notice of Medicare Non-Coverage . policy documented, .A Medicare provider .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing .services .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service of care is not being provided daily .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .The effective date coverage of your current Medicare Part A Service will end: 7-19-17 . There was no signature of the resident or resident representative indicating advance notice was provided. The Discharge Summary documented a discharge date of [DATE]. 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The NOTICE OF MEDICARE NON-COVERAGE form documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT .Skilled Rehab (Rehabilitation) .SERVICES WILL END: 9-15-17 . There was no signature of the resident or resident representative indicating advance notice was provided. Resident #28 was still residing at the facility, 4. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .The effective date coverage of your current Medicare Part A Service will end: 6-11-17 . There was no signature of the resident or resident representative indicating advance notice was provided. The Discharge Summary documented a discharge date of [DATE]. Interview with the Minimum Data Set (MDS) Coordinator on 11/21/17 at 11:11 AM, in the Activities Room, the MDS Coordinator was asked whether anyone signed for notification of end of medicare services for Resident #16, 28, or 44. The MDS Coordinator stated, I just mail those out to the RP (Responsible Party), and I ask them to bring it back in to me. Most of the time they don't. The MDS Coordinator was asked whether he documented when he mailed the notices. The MDS Coordinator stated, No . The MDS Coordinator was asked if he sent the notices by certified mail. The MDS Coordinator stated, No . The facility was unable to provide evidence that advanced notice was provided for Resident #16, #28, and #44 before the ending of Medicare-covered services.",2020-09-01
2809,SWEETWATER NURSING CENTER,445456,978 HWY 11 SOUTH,SWEETWATER,TN,37874,2017-12-13,881,C,0,1,4B6W11,"Based on facility policy review and interview the facility failed to implement an Antibiotic Stewardship Program for 80 of 80 residents currently on census. The findings included: Review of the Antibiotic Stewardship Policy revised 12/2016 revealed .It is the policy of this facility to follow an Antibiotic Stewardship program .The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events .Antibiotic Stewardship is part of our Infection Prevention & Control Program . Review of General Policies revised 2/2017 revealed .It shall be the responsibility of the Administrator/Executive Director, through the Infection Prevention & Control aspect of the Quality Assurance Performance Improvement Committee to assure that Infection Prevention & Control policies and procedures are implemented and followed . Interview with the Director of Nursing on 12/13/17 at 3:25 PM, in the chapel, confirmed she was not aware of the antibiotic stewardship program. Interview with the Nurse Consultant on 12/13/17 at 5:00 PM, outside of the chapel , confirmed the facility held a meeting to discuss the antibiotic stewardship program but had failed to implement the program.",2020-09-01
2813,MADISONVILLE HEALTH AND REHAB CENTER,445457,465 ISBILL RD,MADISONVILLE,TN,37354,2019-05-20,842,C,1,0,HYGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record reviews, observations, and interviews, the facility failed to store medical record documents designated for destruction in secure containers to prevent unauthorized access or use, for 3 Residents, (Residents #1, #2 and #3) of 3 residents reviewed for privacy, on 2 of 2 units. The findings included: Review of the facility policy, Retention of Records, revised 2006, revealed .inactive records .will be destroyed Review of the facility policy Protected Health Information (PHI), Management and Protection, revised (MONTH) 2014, revealed .it is the responsibility of all personnel who have access to resident and facility information .to ensure .information is managed and protected .to prevent unauthorized .disclosure . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations made throughout the facility during the initial tour revealed a lack of secure document destruction containers. Observations of the DON office and interview with the DON on 5/20/19 at 1:00 PM, revealed 18 card board boxes, with tops folded closed stored along the walls. All 18 boxes contained paper documents with protected health information for facility residents designated to be destroyed. The DON reported her office was locked when she was out of the building, but acknowledged the documents were not secured as stored, if her office door was left open while she was in the facility. The DON reported she had stored records awaiting destruction in her office since (MONTH) of 2019. Observation of the outside storage building and interview with the maintenance director on 5/20/19 at 1:20 PM, revealed 64 cardboard boxes of varying sizes stored there. Examinations of the boxes stored in the most accessible areas, revealed all were filled with medical record documents which contained protected health information, awaiting destruction. The maintenance director reported prior to (MONTH) 2019, the facility did not store medical records of any type there. The maintenance director confirmed the records as stored, could be accessed by unauthorized persons. Observations of the nursing station on 5/20/19 at 2:45 PM, revealed a large, open topped, cardboard box was in use beneath the desk, in which were stored various medical record documents slated for destruction. The box was not secured, and documents inside it, could be viewed or withdrawn by anyone behind the desk. Documents pulled from the box included admission orders [REDACTED]#3. Interview with the Administrator on 5/20/19 at 3:00 PM, in the conference room, revealed the Administrator reported the facility document destruction provider had terminated its' contract with the facility corporate office sometime in early (MONTH) 2019. The document destruction provider had repossessed its' locked shred boxes at the facility and since (MONTH) 2019, no alternate provider had been contracted to provide secure document destruction for the facility. The Administrator reported she had made multiple requests to the Corporate Nurse and Corporate Vice President of Operations related to the matter, and was informed by her supervisors, the requests had been forwarded to the Corporate Office for resolution, but confirmed as of 5/20/19, no action had been taken by the Corporate Ownership to resolve the matter. The Administrator confirmed surveyor observations of unsecured documents awaiting destruction in the DON office, storage building and behind the nursing station were not in accordance with corporate policies and the facility had failed to secure medial record documents with protected health information in a fashion to prevent access by unauthorized persons.",2020-09-01
2981,LIFE CARE CENTER OF GRAY,445479,791 OLD GRAY STATION ROAD,GRAY,TN,37615,2018-10-31,921,C,1,1,7ZGX11,"> Based on facility policy review, observation and interview the facility failed to provide a safe, sanitary, and comfortable environment for all residents on 4 of 4 halls observed in the facility. The findings include: Review of the facility policy, Preventive Maintenance- Exhaust Fan Inspection, revealed .all exhaust fans will be inspected on a monthly basis or more often if needed . Observations made 10/29/18 through 10/31/18 during the survey revealed multiple rooms on 4 of 4 hallways with a large amount of dust and debris in the residents' bathroom exhaust fan vents. Interview with the Maintenance Director on 10/31/18 at 12:50 PM, in the hallway, confirmed the exhaust fan vents were in need of cleaning and were not on a set cleaning schedule.",2020-09-01
3037,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2017-05-17,356,C,0,1,LW9W11,"Based on observation and interview, the facility failed to post the current resident census and nurse staffing data for 1 day of 3 days observed. The findings included: Observation on 5/8/17 at 12:32 PM, at the main entrance receptionist desk, revealed the facility staffing sheet posted was missing the current resident census and nurse staffing hours. Observation on 5/8/17 at 12:40 PM, at the upstairs nurse's station, revealed the facility staffing sheet posted was missing the current resident census and nurse staffing hours. Interview with Director of Nursing on 5/8/17 at 12:40 PM, at the upstairs nurse's station, confirmed the census and staffing sheets posted were incorrect.",2020-09-01
3055,SENATOR BEN ATCHLEY STATE VETERANS' HOME,445484,ONE VETERANS WAY,KNOXVILLE,TN,37931,2017-03-07,372,C,0,1,ENX011,"Based on observation and interview, the facility failed to dispose of garbage and refuse in a sanitary manner for 3 of 3 dumpsters observed. The findings included: Observation with the Assistant Dietary Manager on 3/5/17 at 9:30 AM, outside at the dumpster area, revealed: a). six blue disposable gloves. b). dried debris on the ground along the base of the middle dumpster c). multiple cigarette butts d). empty condiment packages, an empty potato chip bag, small pieces of paper, and a card board food package. All items were on the ground behind the dumpsters. Interview with the Assistant Dietary Manager on 3/5/17 at 9:35 AM, outside at the dumpster area confirmed the facility failed to dispose of garbage and refuse in a sanitary manner Interview with the Director of Clinical Services on 3/6/17 at 11:19 AM, in the conference room confirmed the dumpster area had not been maintained in a sanitary manner.",2020-09-01
3056,SENATOR BEN ATCHLEY STATE VETERANS' HOME,445484,ONE VETERANS WAY,KNOXVILLE,TN,37931,2019-04-24,657,C,0,1,OQ0X11,"**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 provide documentation of Certified Nurse Aide (CNA) participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) of 37 residents reviewed. The findings include: Review of the facility policy Clinical Comprehensive Care Plans Policy, dated 3/1/16 revealed .utilize information gathered .to develop, review and revise the Resident's Comprehensive Plan of Care .the Care Planning/Interdisciplinary Team .develops and maintains a comprehensive plan of care .that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions .include, but not limited to .Nursing Assistants . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/31/18 and 1/9/19 revealed no documentation of CNA participation for Resident #7. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #8. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/24/19 revealed no documentation of CNA participation for Resident #18. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/8/18 and 2/11/19 revealed no documentation of CNA participation for Resident #24. Medical record review revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 1/22/19 revealed no documentation of CNA participation for Resident #31. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/23/18 and 2/25/19 revealed no documentation of CNA participation for Resident #45. Medical record review revealed Resident #48 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 2/26/19 revealed no documentation of CNA participation for Resident #48. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 2/24/19 revealed no documentation of CNA participation for Resident #50. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/17/19 revealed no documentation of CNA participation for Resident #55. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #69. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 1/3/19 and 3/21/19 revealed no documentation of CNA participation for Resident #83. Medical record review revealed Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting dated 4/2/19 revealed no documentation of CNA participation for Resident #95. Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #104. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/29/19 revealed no documentation of CNA participation for Resident #108. Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/3/18 and 12/10/18 revealed no documentation of CNA participation for Resident #110. Medical record review revealed Resident #111 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting dated 3/22/19 revealed no documentation of CNA participation for Resident #111. Medical record review revealed Resident #112 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/11/19 revealed no documentation of CNA participation for Resident #112. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/22/19 revealed no documentation of CNA participation for Resident #115. Medical record review revealed Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 12/12/18 and 1/9/19 revealed no documentation of CNA participation for Resident #118. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/3/19 revealed no documentation of CNA participation for Resident #121. Interview with the Director of Nursing, the Minimum Data Set (MDS) Coordinator, MDS Coordinator Registered Nurse #1 and MDS Licensed Practical Nurse #1 on 4/24/19 at 12:55 PM, in the D Wing MDS office, confirmed the facility failed to provide documentation of CNA participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) residents.",2020-09-01
3066,"STONERIDGE HEALTH CARE, LLC",445486,5121 GREER ROAD,GOODLETTSVILLE,TN,37072,2018-04-25,881,C,0,1,1BNF11,"Based on infection control review and interview, the facility failed to develop and implement an Antibiotic Stewardship program. The findings included: Interview and review of the facility infection control program with the Assistant Director of Nursing (ADON) on 4/25/18 at 8:00 AM, in the conference room revealed there was no documentation the facility had an Antibiotic Stewardship Program. Interview with the ADON confirmed the facility had not developed an Antibiotic Stewardship Program.",2020-09-01
3109,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2017-04-26,253,C,0,1,SXEG11,"Based on observation and interview the facility failed to provide and maintain a clean, safe, comfortable and homelike environment in resident's rooms and resident's shared common areas for 2 of 3 units observed in the facility. The findings included: Observations of resident' rooms during the environmental tour on 4/26/17 at 9:35AM with the Maintenance Director, revealed the following: 1. Rooms 177 East (E), 260E, 267E and 282E, had over-the-bed tables with missing areas of veneer which allowed the sharp edges of the wood to be exposed. 2. Room 177E had several brown stains on the wall near the bed and bathroom. 3. The 2 East Lounge/TV area had a black over-stuffed recliner with several large areas on the arms of the chair with missing vinyl exposing the cloth material beneath. A brown recliner in this same area had two large holes in the vinyl on the right side of the chair exposing the material beneath and prevented the chairs from being sanitized after use. 4. Room 266E had a leaky bathroom faucet that continued to leak water even after both handles were turned to the off position. The Maintenance Director confirmed at this time that the faucet could not be shut off and should be replaced. 5. Rooms 267E and 260E had bathroom toilet risers with areas were the paint had been chipped exposing the bare metal beneath, and prevented the resident's equipment from being sanitized effectively after use. 6. Rooms177E, 267E-Bed A, and 263E- Bed A, had drywall behind the head of the bed that was marred and gouged. In the residents' bathroom for rooms 266E and 269E, the drywall corner wall edges were gouged and had areas of missing cove base. The drywall below the air conditioner unit in room 266E was gouged and had an area that was missing drywall. Black marks were observed along the walls in room 266E-Bed [NAME] 7. Room 267E-Bed A, had a blue floor mat with a tear in the corner of the vinyl exposing the foam beneath, thus preventing the item from being sanitized after use. 8. Room 269E and 267E, the closet doors were off the tract and would not open. The Maintenance Director confirmed that the closet doors were off the tract and was in need of repair. 9. Room 167E-Bed A, the carpet had several areas that were stained and the cords/outlets for the cable protruded from the wall. 10. Rooms 279E- Bed A, 266E- Bed A, and 263E- Bed A, had wheelchairs with vinyl-covered armrests that were cracked, exposing the material beneath. The Maintenance Director confirmed that the vinyl surfaces had sharp edges. 11. Room 267E, had the heat/air conditioner unit rusted over on the exterior and interior of the unit, thus preventing the unit from being cleaned or sanitized. 12. Room 267E- Bed B, the cubicle curtain had areas of brown stain. 13. Room 263E, the drain was missing from the resident's bathroom faucet. The toilet paper bar was missing which prevented the roll of toilet paper from being attached to the toilet roll holder. Interview with the Maintenance Director on 4/26/17 at 12:30 PM, indicated the maintenance staff viewed each resident's room once a month for maintenance repair issues. The Maintenance Director provided the surveyor with documents titled, Department Monthly PM (preventative maintenance) Check List dated January, February, (MONTH) and (MONTH) (YEAR). Review of the documentation in the presence of the Administrator and Maintenance Director revealed all of the documents indicated the items were OK. The Maintenance Director confirmed the facility staff failed to identify maintenance and housekeeping issues.",2020-09-01
3200,THE MEADOWS,445496,8044 COLEY DAVIS ROAD,NASHVILLE,TN,37221,2019-06-05,607,C,0,1,T6TK11,"Based on facility policy review, record review and interview, the facility failed to have abuse registry checks for 8 of 8 employee personnel files reviewed. The findings include: Facility policy review, Personnel File Maintenance, revised 4/1/15, revealed .Specific documents relating to individuals' employment with the company are maintained in their personnel files. The following may be maintained in a separate file: company and/or state required criminal background check report . Record review on 6/5/19 at 12:00 PM revealed 8 employee personnel files did not obtain abuse registry checks until 6/4/19. Interview with the Payroll/Bookkeeper on 6/5/19 at 3:10 PM in her office confirmed it was a miscommunication problem between the staffing coordinator and her (payroll/bookkeeper) as to who was to complete and place the abuse registry checks in the personnel files. Interview with the Administrator on 6/5/19 at 3:30 PM in his office confirmed confirmed 8 of 8 records reviewed did not contain abuse registry checks prior to the survey.",2020-09-01
3324,GOOD SAMARITAN SOCIETY - FAIRFIELD GLADE,445506,100 SAMARITAN WAY,CROSSVILLE,TN,38558,2019-11-14,655,C,0,1,69HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide evidence of documentation in the medical record indicating a Baseline Care Plan summary was given to the resident and/or resident representative for 6 Residents (#1, #16, #21, #22, #34, and #195) and failed to develop a Baseline Care Plan timely for 1 Resident (#16) of 6 residents reviewed for Baseline Care Plans. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 11/1/19 revealed no documented evidence Resident #1 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 5/21/19 revealed no documented evidence Resident #16 and/or the resident representative had received a summary of the Baseline Care Plan. Continued review revealed the Baseline Care Plan was dated 6 days after the admitted . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/24/18 revealed no documented evidence Resident #21 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 9/23/19 revealed no documented evidence Resident #22 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/14/19 revealed no documented evidence Resident #34 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 11/8/19 revealed no documented evidence Resident #195 and/or the resident representative had received a summary of the Baseline Care Plan. Interview with the Director of Nursing (DON) on 11/14/19 at 9:36 AM, in the conference room, confirmed the facility did not have documented evidence in the medical record Resident #1, Resident #34, or Resident #195, or the resident representatives had received a summary of the Baseline Care plan. Interview with the DON on 11/14/19 at 1:37 PM, in the DON's office, confirmed the facility did not have documented evidence in the medical record Resident #16, Resident #21, or Resident #22 or the resident representatives had received a copy of the baseline care plan. Interview with the DON on 11/14/19 at 4:08 PM, in the conference room, confirmed the Baseline Care Plan had not been completed timely, within 48 hours of admission to the facility, for Resident #16.",2020-09-01
3498,LAKESHORE HEARTLAND,445526,3025 FERNBROOK LANE,NASHVILLE,TN,37214,2017-06-27,356,C,0,1,1W5Z11,"Based on observation and interview, the facility failed to ensure staffing was posted correctly on 1 of 3 days. The findings included: Observation on 6/25/17 at 10:10 AM, in the front lobby, revealed the daily staff posting dated 6/25/17 for the 6 AM to 6 PM shift indicated 1 Registered Nurse (RN), 2 Licensed Practical Nurses (LPN) and 8 Certified Nurse Technicians (CNT) were working. Observation and interview with the Director of Nursing (DON) on 6/25/17 at 10:10 AM, in the front lobby, confirmed the posted staffing was incorrect. Continued interview revealed 3 LPN's and 6 CNT's were on duty for the 6 AM to 6 PM shift.",2020-09-01
3640,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,156,C,0,1,K3HH11,"Based on medical record review and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #8,17 and 28) sampled residents reviewed for liability and appeal notices. The findings included: Medical record review revealed Resident #8 had a therapy end date of 5/7/17 with a documented telephone notification on 5/4/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #8's responsible party (RP). Medical record review revealed Resident #17 had a therapy end date of 2/10/17 with a documented telephone notification on 2/5/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #17's responsible party. Medical record review revealed Resident #28 had a therapy end date of 3/13/17 with a documented telephone notification on 3/7/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #28's responsible party. Interview with the Business Office Manager on 5/23/17 at 4:26 PM, in the conference room, the Business Office Manager stated, I failed to tell you that we did not send letters to those family members. The Business Office Manager was asked if she could provide any proof that the letters were sent. The Business Office Manager stated, No ma'am they were never sent. Interview with the Administrator on 5/23/27 at 4:45 PM, in the conference room, the Administrator stated, .no letters were mailed out . Interview with the Social Services Director on 5/23/17 at 5:48 PM, in the Administrator's office, the Social Services Director was asked if Resident #28 was his own patient representative because his notification letter stated he refused to sign. The Social Services Director stated, No his ex-wife is his RP. The Social Services Director was asked if Resident #28's RP should have been the person receiving the liability appeal letter. The Social Services Director stated, Yes.",2020-04-01
3641,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,160,C,0,1,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the facility's Detail Admission/Discharge Report, and interview, the facility failed to refund 2 of 8 (Resident #20 and 65) sampled residents' account balances within 30 days of death. The findings included: 1. The facility's FINANCIAL AGREEMENT policy documented, .If a Resident that has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual or probate jurisdiction administering the Resident's estate or other entity as required by State law or regulation . 2. Review of the facility's Detail Admission/Discharge Report revealed the following: a. Resident #20 expired on [DATE] and the account balance was not refunded until [DATE], a total of 80 days later. b. Resident #65 expired on [DATE] and the account balance was not refunded until [DATE], a total of 81 days later. Telephone interview with the Accounts Receivable Manager on [DATE] at 8:37 AM, the Accounts Receivable Manager was asked how long it should take to refund the resident's account balance after the resident expired. The Accounts Receivable Manager stated, We try to do that in 30 days .I know there are some that have been late. The Accounts Receivable Manager was asked if it was acceptable to not refund the residents' account balance within 30 days after the resident expired. The Accounts Receivable Manager stated, No ma'am.",2020-04-01
3812,HOLSTON MANOR,445295,3641 MEMORIAL BLVD,KINGSPORT,TN,37664,2016-12-14,356,C,0,1,RJIW11,"Based on observation and interview the facility failed to post accurate staffing data and record the census for 12/12/16. The findings included: Observation of posted staffing data on 12/12/16 at 9:50 AM, revealed staffing was posted as follows: a. Registered Nurses (RN) 4 b. Licensed Practical Nurses (LPN) 9 Continued observation revealed the census for 12/12/16 was not posted. Interview with the Director of Nursing (DON) on 12/12/16 at 10:15 AM, in the DON's office revealed there were 3 RN's and 6 LPN's currently currently working and confirmed the staffing data posted was not accurate and did not reflect the current census.",2020-02-01
3898,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,167,C,0,1,N3NC11,"Based on observation and interview, the facility failed to label and place the state survey results in a readily accessible location for resident use. The findings included: Observation of the first floor lobby on 10/19/16 at 10:00 AM, revealed the state survey results were in an unlabeled basket attached to the wall above the chair rail. Further observation revealed the first floor contained the kitchen, bookkeeping, business office, and laundry room. Interview with the Administrator on 10/19/16 at 1:25 PM, on the first floor, confirmed the facility failed to label and place the results of the state survey in a location readily accessible to residents.",2020-01-01
3909,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,356,C,0,1,7T7F11,"Based on observation and interview, the facility failed to post the nurse staffing information on a daily basis for 2/4/17 and 2/5/17. The findings included: Observation on 2/6/17 at 9:05 AM in the front lobby of the facility, during the initial tour, revealed the facility failed to post the nurse staffing information for 2/6/17. Interview with Licensed Practical Nurse (LPN) #1 on 2/6/17 at 9:20 AM at the AB nurse's station confirmed the nurse staffing information was not posted for 2/4/17 and 2/5/17. Continued interview with LPN #1 confirmed the daily nurse staffing information for 2/6/17 was posted by 10:00 AM. Interview with the Director of Nursing (DON) on 2/7/17 at 1:30 PM in the classroom confirmed the facility failed to post the nurse staffing information for 2/4/17 and 2/5/17.",2020-01-01
3992,"NHC HEALTHCARE, SMITHVILLE",445116,825 FISHER AVE P O BOX 549,SMITHVILLE,TN,37166,2016-10-04,356,C,0,1,SH5D11,"Based on observation and interview, the facility failed to post accurate nurse staffing information in 1 of 3 observations. The findings included: Observation on 10/2/16, at 9:32 AM, in the main entrance foyer, revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for 9/29/16, and had not been updated to reflect current nursing staff in the facility on 10/2/16. Interview with Licensed Practical Nurse #1, on 10/2/16 at 9:35 AM, in the main entrance lobby, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate staffing.",2019-11-01
4075,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-07-20,356,C,0,1,VGPG11,"Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 7/18/16 at 9:15 AM, in the facility's main entrance revealed the nurse staffing sheet posted was dated 7/15/16. Interview with the Director of Nursing on 7/18/16 at 9:18 AM, in the facility's main entrance confirmed the nurse staffing sheet posted was not for the current date.",2019-11-01
4081,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2017-01-11,356,C,0,1,XT5X11,"Based on observation and interview, the facility failed to post staffing in a prominent place readily accessible to residents and visitors. The findings included: Observation on 1/9/17, at 9:40 AM at the back hall corridor, between the 100 and 200 Hall nurses station, revealed the staffing information posting. The staffing posting was not in a prominent place readily accessible to residents and visitors. Interview with the Assistant Director of Nursing on 1/11/17 at 2:19 PM in front of the staffing posting on the back hall corridor, between the 100 and 200 Hall nurses station, confirmed the staffing information was not in a prominent place readily accessible to residents and visitors",2019-11-01
4175,LEWIS COUNTY NURSING AND REHABILITATION CENTER,445430,"119 KITTRELL ST, PO BOX 129",HOHENWALD,TN,38462,2017-01-19,156,C,0,1,ZHG411,"Based on record review and interview, the facility failed to provide the appropriate liability and appeal for 1 of 4 (Resident #74) sampled residents reviewed for liability and appeal notices. The findings included: Review of the advanced beneficiary notices on 1/20/17 at 6:40 PM, in the Admissions Office, the facility was unable to provide an advanced beneficiary notice for Resident #74. Interview with the Social Services Director (SSD), on 1/18/17 at 6:48 PM, in the Admissions Office, the SSD stated, .I couldn't find the letter (advanced beneficiary letter) for (Named resident) .I think she went long term care .I dropped the ball on it .she had additional days left .",2019-11-01
4254,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2016-09-29,356,C,0,1,1KSC11,"Based on policy review, observation and interview, the facility failed to post current and accurate nurse staffing information at the beginning of each shift during 3 of 3 (9/18/19, 9/19/16 and 9/23/16) days of observing the posted nursing staff information. The findings included: 1. Review of the Nursing Staff Hours policy documented Nursing Hours will be posted in accordance with state and federal Regulations .The following information shall be posted on a daily basis at the beginning of each shift .The number and actual hours worked by licensed and unlicensed staff responsible for resident care, including RNs (Registered Nurses), LPNs (Licensed Practical Nurses) and CNAs (Certified Nursing Assistants). 2. Observations during the initial tour of the facility on Sunday, 9/18/19 at 2:10 PM, revealed the nurse staffing information was posted in the window of the business office. The posting was dated for Friday, 9/16/16 and included all three shifts and the total census. Observations on 9/18/16 at 3:45PM and 9/18/16 at 6:30 PM revealed the posted information for Friday, 9/16/16, remained posted. Observations on Sunday, 09/18/16 at 11:30 PM revealed the nursing staff information posted in the window of the business office was dated for Sunday, 9/18/16, and included all three shifts and the total census. Observations upon entrance into the facility on Monday, 9/19/16 at 9:25 AM, revealed the nurse staffing information was posted in the window of the business office. The staffing information posted was dated Sunday, 9/18/16, and included all three shifts and the total census. Observations of the nursing staff information posted in the business office window on Monday, 9/19/16 at 11:55 AM, revealed nursing staff information dated for Sunday, 9/18/16. The Regional Nurse exited the Administrators office to point out the Staff Posting was taped to the wall next to the facility license. The Regional Nurse stated she placed it there that morning because the business office was not opened. Surveyors reviewed the the same wall at 9:25 AM and the posting was not present at that time. The posting taped to the wall by the facility license was not eye level to the residents in wheelchairs. Observations during an off hour visit on 9/23/16 at 9:33 PM revealed the nurse staffing information posted for Friday 9/23/16 was inaccurate. The posting documented 12 hour RN (Registered Nurse) coverage for 7PM to 7AM; however, it was confirmed there was no RN coverage for the 7PM to 7AM shift. The posting was removed from the glass window in the business office on 9/24/16 at 8:37 AM. 3. Interview with the the Business Office Manager (BOM) on 9/19/16 at 9:30 AM, in the Business office, the BOM confirmed the staff posting sheet posted was not the current date. The BOM stated the nurses usually did that. The business office manager confirmed the nurse supervisor had a key to the business office. Interview with the BOM on 9/21/16 at 9:28 AM, in the Business office, the BOM confirmed the Human Resource Clerk (HRC) reported to work on 9/19/16 at 7:00AM and she got there at 7:30 AM on 9/19/16. The BOM confirmed the business office was open and unlocked at 7:00 AM, and remained unlocked throughout the day until the business office staff leaves for the day, normally at 5:00 PM. The BOM again confirmed the midnight nurse has a key to get into the business office to post the staffing sheet daily. Interview with RN #1 on 9/27/16 at 7:03 AM, in the North Hall RN #1 stated she usually posted the nurse staffing information about 3:00 AM for the next day when she was scheduled to work. RN #1 confirmed she worked 9/16/16, 9/17/16 and 9/18/16 and should have posted the staffing sheet but she did not because she had to work the cart and do supervisory duties. RN #1 stated she did have a key to the business office but just didn't have time to do it. RN #1 stated over the last few weeks she had missed posting the staffing sheet a few times other than the weekend before because she and the other nurse was behind on their work. RN #1 stated she had reported to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that she did not have enough time to get everything done on her shift. RN #1 stated when she does post the staff posting it is for all three shifts. Interview with RN #5 on 9/23/16 at 10:15 PM, outside the Conference room, RN #5 was asked if the posted staffing information was accurate for 9/23/16, 7:00 PM to 7:00 AM. RN #5 stated, .(RN #1) called out and is supposed to be here .the Staffing Coordinator is supposed to keep the staff posting up to date and time . RN #1 confirmed the staff posting was not accurate.",2019-10-01
4305,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2016-09-30,203,C,0,1,H2DS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Title 42 (42) Code of Federal Regulations (C.F.R.), 483.12 Admission, Transfer and Discharge Rights, medical record review, and interview, the facility failed to include the location to which the resident was transferred or discharged on the 30 day notice of discharge for 6 of 6 (Resident # 58, 71, 89, 138, 156 and 188) sampled residents reviewed for involuntary discharge. The findings included: 1. The 42 C.F.R. 483.12 (a) . documented, .(4) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .(6) Contents of the notice. The written notice specified in paragraph (a) (4) of this section must include the following .(iii) The location to which the resident is transferred or discharged . 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 16, (YEAR) documented, .(Named Resident #58) will be transferred to another skilled nursing facility &/or care home placement . The FINAL ADMINISTRATIVE ORDER dated (MONTH) 26, (YEAR) documented, .it is determined that (Named Nursing Home) may not involuntarily transfer or discharge Respondent at this time. This determination is based on the following findings of fact and conclusions of law .8. The discharge notice does not contain a discharge location . 3. Medical record review revealed Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 23, (YEAR) documented, .Re: (Named Resident #71) .The Resident or Responsible Party has been informed that they must make alternative living arrangements on or before (MONTH) 23, (YEAR) . Resident #71 has appealed this notice, and the hearing is scheduled for (MONTH) 13, (YEAR). 4. Medical record review revealed Resident #89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 6, (YEAR) documented, .RE: (Named Resident #89) .(Named Resident #89 will be transferred to another skilled nursing facility &/ or care home placement . The FINAL ADMINISTRATIVE ORDER dated (MONTH) 14, (YEAR) documented, .it is determined that (Named Nursing Home) may not involuntarily transfer or discharge Respondent at this time. This determination is based on the following findings of fact and conclusions of law .9. The discharge notice does not contain a discharge location . 5. Medical record review revealed Resident #138 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 16, (YEAR) documented, .(Named Resident #138) will be transferred to another skilled nursing facility &/or care home placement . The FINAL ADMINISTRATIVE ORDER dated (MONTH) 26, (YEAR) documented, .it is determined that (Named Nursing Home) may not involuntarily transfer or discharge Respondent at this time. This determination is based on the following findings of fact and conclusions of law .7. The discharge notice does not contain a discharge location . 6. Medical record review revealed Resident #156 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 10, (YEAR) documented, .(Named Resident #156) will be transferred to another skilled nursing facility &/or care home placement . The FINAL ADMINISTRATIVE ORDER dated (MONTH) 26, (YEAR) documented, .it is determined that (Named Nursing Home) may not involuntarily transfer or discharge Respondent at this time. This determination is based on the following findings of fact and conclusions of law .8. The discharge notice does not contain a discharge location . 7. Medical record review revealed Resident #188 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 10, (YEAR) documented, .(Named Resident #188) will be transferred to another skilled nursing facility &/or care home placement . There was no documentation that Resident #188 had appealed this notice. Resident #188 was a resident in the facility at the time of the survey. Interview with Social Worker (SW) #1 on 9/28/16 at 4:08 PM, in the SW office, SW #1 was asked about the process of issuing 30 day discharge notices. SW #1 stated, .First, we counsel, then educate them on the smoking policy and notify the RP (Responsible Party) and also educate them on this (smoking policy). If caught again with a cigarette or lighter, we counsel them, then notify the family and educate the family and re-educate. On the 3rd time we issue the 30 day notice and contact the family and let them know. SW #1 was then asked if the location the resident is going to be discharged to, was documented on the 30 day discharge notice. SW #1 stated, Well, no. If the family does not appeal, then we fax off referrals to other facilities and other alternative living arrangements. SW #1 was asked do you do this before the notice is given to them. SW #1 stated, No ma'am, if they do appeal, we don't because they could win and stay here. SW #1 was asked again do you list a specific location a resident will be discharged to in the 30 day discharge letter. SW #1 stated, No ma'am, not in the letter.",2019-10-01
4347,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2016-10-13,356,C,1,0,0FBG11,"> Based on observation and interview, the facility failed to post the current nurse staffing information in a prominent place readily accessible to residents and visitors during 2 days of the survey. The findings included: Observation upon entering the facility on 10/5/16 at 11:30 PM and on 10/6/16 at 7:45 AM revealed the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Interview with Director of Nursing on 10/6/16 at 12:15 AM at the C Hall Nurses Station confirmed the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors.",2019-10-01
4400,LAURELWOOD HEALTHCARE CENTER,445413,200 BIRCH ST,JACKSON,TN,38301,2016-10-27,170,C,0,1,6DH211,"Based on policy review and interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays. The facility reported a current census of 59 residents. The findings included: The facility's Attachment B - Resident Rights - Federal policy documented, .I. Mail. The resident has the right to privacy in written communication, including the right to: 1. Send and promptly receive mail that is unopened . Interview with the Resident #40 in her room on 10/24/16 at 10:10 AM, Resident #40 was asked if the mail is delivered unopened and on Saturdays. Resident #40 stated, No, and it is opened to make sure it is OK . Interview on 10/27/16 at 9:29 AM, in the Social Worker office, the Social Worker (SW) was asked if residents receive mail unopened on Saturdays. The SW stated, No, the mail is gone through to make sure it's ok, then its passed out on Monday . Interview on 10/27/16 at 11:04 AM, in the day room, the Activity Director (AD) was asked about how residents in the facility receive mail. The AD stated, One of my duties is collecting the mail and distributing it to residents .everyday I check if they have mail, and I will distribute it. The AD was asked why residents do not receive mail on Saturday. The AD stated, I am not here on Saturday, so there is nobody to do it . Interview on 10/27/16 at 11:11 AM, in the Business office, the Human Resources Person (HRP) was asked about the residents receiving mail on Saturdays. The HRP stated, We are not here on Saturday. Saturday's mail gets distributed on Monday. Interview on 10/27/16 at 11:40 AM, in the day room, the Administrator was asked if the residents receive mail unopened on Saturday. The Administrator said, No.",2019-10-01
4497,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2016-06-03,241,C,0,1,3OTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a homelike environment and to maintain dignity and respect observed during 2 of 2 dining experiences and in 2 of 2 dining rooms. The findings included: Review of facility policy, Meal Service, dated 6/1/08 revealed .Meals are served in a manner that enhances each patient/resident's dignity and in an environment that is as home-like as possible . Observation during lunch dining on 5/31/16 at 12:30 PM revealed lunch was served with the plates and other items left on the trays. Continued observation revealed milk and juice were not poured into glassware but was served in the cartons with straws for 8 residents. Observation during breakfast dining on 6/1/16 at 8:00 AM revealed breakfast was served with the plates and other items left on the trays. Continued observation revealed the milk was not poured into glassware but was served in the cartons with straws for 7 residents, juice was not poured into glassware but was served in the cartons with straws for 9 residents and pre-packaged cereal was served to 4 residents. Observation during lunch dining on 5/31/16 at 12:00 PM, in the A wing dining room revealed lunch was served with the plates and other items left on the trays. Continued observation revealed milk, juice, and ensure, were not poured into glassware but was served in the cartons with straws for 20 residents. Continued observation revealed 1 resident was served a peanut butter and jelly sandwich in a clear plastic to go container. Observation during breakfast dining on 6/1/16 at 8:00 AM, in the A wing dining room revealed breakfast was served with the plates and other items left on the trays. Continued observation revealed the milk, juice, and ensure, was not poured into glassware but was served in the cartons with straws for 14 residents. Continued observation revealed sausage gravy, fried eggs, and boiled eggs were served in Styrofoam bowls. Continued observation revealed 3 residents were served muffins in clear plastic to go containers. Interview with the Administrator and the Registered Dietician on 6/2/16 at 11:20 AM, in the conference room confirmed the goal is to not have disposables and are in the process of going to fine dining, just not there yet .having monthly in services on fine dining and even [MEDICATION NAME] serving the meals. Further interview confirmed they have never had a complaint regarding the drinks being in cartons, the cereal being prepackaged or the plates being left on trays.",2019-09-01
4513,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2016-07-07,356,C,0,1,JVL711,"Based on observation and interview, the facility failed to ensure the Nurse Staffing data posted was correct. The findings included: Observation during the initial tour on 7/5/16 at 10:30 AM, inside the main entrance revealed the Nurse Staffing posted listed 8 Registered Nurses (RNs) working on the day shift. Further observation revealed 5 RNs were working direct care. Interview with the Director of Nursing (DON) on 7/7/16 at 9:40 AM, in the DON's office confirmed there were only 5 RNs working direct care and the Nurse Staffing posted was incorrect.",2019-09-01
4696,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2016-05-11,159,C,0,1,J48A11,"Based on policy review, review of residents' balances, and interview, the facility failed to ensure residents receiving Medicaid funding balances did not exceeded the Supplemental Security Income (SSI) limit for 17 of 163 (Residents #4, 28, 64, 91, 93, 102, 104, 111, 123, 142, 160, 176, 178, 182, 185, 196, and 198) residents with accounts in the facility during the first quarter of (YEAR) as of (MONTH) 31, (YEAR). The findings included: 1. The facility's Personal Funds policy documented, POLICY: To provide uniform guidelines to manage the finances of residents who choose to have the facility manage their personal funds .Resource Limit Notification Residents who receive Medical Assistance benefits must maintain a resident fund balance below the Medical Assistance resource limit. The facility will notify a Medicaid resident if his or her account balance is within Two Hundreds Dollars ($200.00) of the allowable resource limit ($2000.00). Resident fund accounts exceeding the resource limit may cause the Resident to be ineligible for Medical Assistance benefits . 2. Review of the account balances as of 3/31/16 revealed the following balances: a. Resident #4 with a balance of $2,202.36. b. Resident #28 with a balance of $5,439.54. c. Resident #64 with a balance of $2,190.47. d. Resident #91 with a balance of $2,241.35. e. Resident #93 with a balance of $2,639.25. f. Resident #102 with a balance of $2,768.87. g. Resident #104 with a balance of $3,149.50. h. Resident #111 with a balance of $2,402.21. i. Resident #123 with a balance of $2,565.45. j. Resident #142 with a balance of $2,543.93. k. Resident #160 with a balance of $2,498.89. l. Resident #176 with a balance of $2,124.56. m. Resident #178 with a balance of $3,312.09. n. Resident #182 with a balance of $3,293.04. o. Resident #185 with a balance of $2,582.65. p. Resident #196 with a balance of $2,147.18. q. Resident #198 with a balance of $2,481.97. 3. Interview with the Business Office Manager (BOM) on 5/11/16 at 5:00 PM, in the BOM office, the BOM was asked about the residents' who had over $2,000.00 in their accounts. The BOM stated, Corporate has been handling that, just turned it back over to us, the plan is to start calling all the families about spinning it down, plan on the Social Worker calling the families .",2019-08-01
4740,ISLAND HOME PARK HEALTH AND REHAB,445476,1758 HILLWOOD DRIVE,KNOXVILLE,TN,37920,2016-06-15,356,C,0,1,0U3911,"Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 6/13/16 at 5:30 AM, in the facility front hall revealed the nurse staffing sheet was dated 6/10/16. Interview with the Assistant Administrator on 6/13/16 at 5:35 AM, in the facility front hall confirmed the nurse staffing sheet posted was not for the current date.",2019-08-01
4857,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-05-04,372,C,0,1,F15O11,"Based on observation and interview, the facility failed to dispose of garbage properly. The findings included: Observation on 5/2/16 at 9:45 AM, with the Certified Dietary Manager and facility Maintenance Director present revealed the facility trash container top lids were open with approximately 20 trash bags over the top of the trash container. Interview with Certified Manager and facility Maintenance Director on 5/2/16 at 9:45 AM, by the facility trash container confirmed the trash container lids were open with trash over the top edge of the container. Continued interview revealed the facility only had one trash container. Further interview revealed the trash was picked up Monday through Friday only. Interview revealed the trash overflow occurred after the Friday pick-up through the Monday morning pick-up.",2019-07-01
4891,"THE WATERS OF JOHNSON CITY, LLC",445487,140 TECHNOLOGY LANE,JOHNSON CITY,TN,37604,2016-05-18,356,C,0,1,NE5911,"Based on observation and interview, the facility failed to post the current nurse staffing data for 1 of 3 days of the survey. The findings included: Observation on 5/16/16 at 7:15 PM of the Nursing Staffing form, posted across from the Administrator's office, revealed the form was dated 5/15/16. Interview with the Administrator on 5/16/16 at 7:15 PM in the Administrator's office confirmed the facility failed to post the 5/16/16 Nursing Staff form.",2019-07-01
4914,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2016-04-20,156,C,0,1,750M11,"Based on review of a Survey and Certification Letter, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #15, 59 and 87) sampled residents reviewed for liability and appeal notices. The findings included: 1. The Survey and Certification Letter Ref (reference): S&C (Survey and Certification) - 09-20 dated 1/9/09 documented, .Notice Delivery to Representatives . Providers are required to develop procedures to use when the beneficiary is incapable . and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact . provider should telephone the representative . Confirm telephone contact by written notice mailed on that same date . 2. The Notice of Medicare Non-Coverage form for Resident #15 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & (and) Therapy) Services Will End: 1/19/16 . Telephone contact was made with the resident's responsible party on 1/14/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 3. The Notice of Medicare Non-Coverage form for Resident #59 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 11/6/2015 . Telephone contact was made with the resident's responsible party on 11/2/15. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 4. The Notice of Medicare Non-Coverage form for Resident #87 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 3/09/2016 . Telephone contact was made with the resident's responsible party on 3/4/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 5. Interview with the Social Worker (SW) on 4/20/16 at 11:00 AM, in the Social Worker's office, the SW was asked if the date on the top of the page was the date she notified the legal representative of the end of their services for Resident #15, 59 and 87. The SW stated, Yes, I called them. The SW was then asked did she have any documentation that the Notice of Medicare Non-Coverage letters were mailed on the date of notice. The SW stated, No, I thought as long as I documented I talked to them then that was all I had to do.",2019-06-01
5117,WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER,445319,32 MEMORIAL DRIVE,WINCHESTER,TN,37398,2016-04-04,356,C,0,1,1YMP11,"Based on observation and interview, the facility failed to post the nurse staffing data for public access on 3/28/16. The findings included: Observation during the initial tour of the facility on 3/28/16 at 7:30 PM revealed nurse staffing data was not posted for public access. Interview with Licensed Practical Nurse (LPN) #1 on 3/28/16 at 7:51 PM at the nurse's station confirmed staffing was not posted for public access. Interview with the Director of Nursing ( DON) on 3/28/16 at 7:55 PM in the front hallway stated the nurse staffing data had not been posted for 3/28/16 and should have been. Further interview confirmed the facility had failed to post the nurse staffing data for public access.",2019-05-01
5262,LIFE CARE CENTER OF CENTERVILLE,445252,112 OLD DICKSON RD,CENTERVILLE,TN,37033,2016-03-10,160,C,0,1,GRJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of written checks, medical record review and interview, the facility failed to refund to the deceased resident's estate the balance of the resident's account within 30 days for 2 of 3 (Resident #130 and 131) residents reviewed with refunds. The findings included: 1. The facility's Recommended Procedures and TIPS/Daily-Monthly RESIDENT FUNDS MANAGEMENT SYSTEM (RFM) policy documented, .Refunds should always be withdrawn timely and sent promptly to the appropriate party . 2. Medical record review revealed Resident #130 expired on [DATE]. Review of a check dated [DATE] documented, pay to the order of (Named Funeral Home). 3. Medical record review revealed Resident #131 expired on [DATE]. Review of a check dated [DATE] documented, Refund from Trust Fund. Interview with the Receptionist on [DATE] at 4:00 PM, in the conference room, the Receptionist verified the refunds were not done within the 30 days as required.",2019-04-01
5364,JEFFERSON CITY HEALTH AND REHAB CENTER,445246,283 W BROADWAY BLVD,JEFFERSON CITY,TN,37760,2016-02-03,372,C,0,1,FX2E11,"Based on policy review, observation, and interview the facility failed to dispose of garbage and refuge properly and maintain a clean environment around the dumpsters and recycled dumpster bin in 1 of 1 dumpster areas observed. The findings included: Review of facility policy, Solid Waste Disposal, undated revealed .Porter .When necessary, empty trash bin into dumpster .Monitor dumpster area for cleanliness . Observation with the Dietary Manager (DM) on 2/1/16 at 9:21 AM, of the dumpster area revealed over 100 cigarette butts, numerous paper and plastic products on the ground surrounding all 4 dumpsters and the 1 recycled dumpster bin. Interview with the DM on 2/1/16 at 9:22 AM, at the dumpster area confirmed the facility failed to dispose of the garbage and refuge properly and failed to maintain a clean environment in the area surrounding the dumpsters and the recycled dumpster bin.",2019-03-01
5441,HILLVIEW HEALTH CENTER,445464,1666 HILLVIEW DRIVE,ELIZABETHTON,TN,37643,2016-03-02,372,C,0,1,WJ4911,"Based on observation and interview the facility failed to maintain a clean and sanitary area around the dumpsters to ensure garbage and refuse were disposed of properly. The findings included: Observation with the Dietary Manager on 3/2/16 at 9:52 AM, of the outside dumpsters revealed the area surrounding 2 dumpsters was littered with soft drink bottles, rubber gloves, paper items and multiple cigarettes butts. Interview with the Dietary Manager on 3/2/16 at 10:01 AM, in the kitchen, confirmed the facility failed to dispose of garbage properly.",2019-03-01
5485,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2015-08-27,356,C,0,1,66JE11,"Based on policy review, observation and interview, the facility failed to post the actual working hours of the nursing staff for 4 of 4 (8/24/15, 8/25/15, 8/26/15 and 8/27/15) days of the survey. The facility identified a census of 95 residents. The findings included: 1. Review of the facility's Staffing Hours Posted policy revealed, nursing hours will be posted daily in an area viewable by the public. 2. Observation on 8/24/15 at 1:20 PM, revealed the nurse staffing data located in a case on the hallway by the front entrance. The facility did not post the actual working hours of the nursing staff. 3. Observation on 8/25/15 at 1:15 PM, on 8/26/15 at 8:35 AM, and on 8/27/15 at 8:50 AM, revealed the facility did not post the actual working hours of the nursing staff. 4. Interview with Administrative Staff A on 8/26/15 at 9:25 AM, revealed the facility did not post the actual working hours of the nursing staff. The facility failed to post the actual working hours of the nursing staff as required.",2019-02-01
5502,CONCORDIA TRANSITIONAL CARE AND REHAB-MARYVILLE,445245,1012 JAMESTOWN WAY,MARYVILLE,TN,37803,2016-01-13,372,C,0,1,SCNY11,"Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris, for 4 of 4 dumpsters observed. The findings included: Review of facility policy, Waste Management for Foodservice, dated 2/28/14 revealed .In the dumpster area: confirm lid or door is closed on the dumpster .do not leave any trash along side .of the dumpster . Observation with the Dietary Manager on 1/11/16 at 1:30 PM, at the dumpster area revealed 4 dumpsters with trash on the ground around the dumpsters including the following: 4 disposable gloves discarded inside out, straws, straw covers, cups, cup lids, drink cans, with other paper and plastic trash. Continued review revealed 1 dumpster door open. Interview with the Dietary Manager on 1/11/16, at 1:30 PM, at the dumpster area confirmed the facility failed to maintain the cleanliness of the dumpster area.",2019-02-01
5615,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,254,C,1,0,8BJL11,"> Based on observation and interview, the facility failed to maintain supplies of clean bath linens sufficient to meet resident needs for 2 of 2 linen storage closets and 6 of 6 clean linen storage carts, on 2 of 2 wings in the facility. The findings included: Observations of the physical environment on 12/3/15 from 12:50 PM to 3:00 PM throughout the facility revealed 2 of 2 clean linen rooms and 6 of 6 clean linen carts on 2 of 2 wings of the facility were devoid of clean towels, wash cloths, and gowns available for resident use (0 clean items were present in any of the areas observed). Observation of the Laundry Room with the Laundry Manager on 12/3/15 at 2:00 PM revealed one 44 gallon plastic barrel contained soiled sheets, towels, wash cloths, and gowns. Continued observation of Dryer Unit #3 revealed the unit was full of clean bed sheets, gowns, bed pads, towels and washcloths. Continued observation of Washer Unit #1 revealed the washer was full of towels. Staff interviews conducted on both wings of the facility between 2:05 PM and 2:20 PM revealed 5 of 5 Certified Nursing Assistants interviewed (CNAs #1, #3, #4, #5, #6) and 3 of 3 Licensed Practical Nurses (LPNs #1, #2, #3) interviewed reported the facility ran out of clean linens on every shift daily and staff members were known to hide clean linens as they became available from the laundry in resident rooms throughout the facility in an effort to maintain sufficient supplies on hand for care of their assigned residents had only exacerbated the problem. Continued interviews with LPNs #1, #2, and #3, on 12/3/15 at 2:20 PM, near the East Wing Nursing Station revealed all 3 nurses reported on a nearly daily basis for several months residents on their units had their showers delayed or postponed until the following shift due to shortages of clean towels and wash cloths. Continued interview revealed LPN #1 reported on multiple occasions staff nurses had complained to the former Director of Nursing (DON) and former Administrator about the shortages and were informed by the former DON to instruct staff to quit hiding clean linens in the resident rooms and no other actions to address the staff concerns were taken. LPN #2 and #3 observed and nodded silently in agreement. Interview with Resident #4 on 12/7/15 at 6:05 PM, in the resident's room revealed the resident was alert and oriented in all spheres. The resident reported on a regular basis he had missed showers as scheduled during 11/2015 due to shortages of bath towels when his showers were rescheduled for later in the day and the CNAs forgot to perform them when towels became available later in the shift. Observation of the East and West Wing linen closets, clean linen carts, and interview with the Laundry Director and Administrator on 12/3/15 at 2:30 PM confirmed all areas observed were devoid of any clean wash cloths, bath towels, or gowns immediately available for resident use and the facility had failed to maintain supplies of clean bath linens sufficient to meet resident needs.",2019-01-01
5670,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2015-09-02,356,C,0,1,EE2W11,"Based on observation and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 1 of 3 days observed. The findings included: Observation on 8/31/15 at 9:55 AM, on the 200 hallway bulletin board, revealed the Posted Nurse Staffing was dated 8/30/15. Interview with the Director of Nursing (DON) on 8/31/15 at 10:00 AM, on the 200 hallway, confirmed the Posted Nurse Staffing was incorrect.",2019-01-01
5702,SWEETWATER NURSING CENTER,445456,978 HWY 11 SOUTH,SWEETWATER,TN,37874,2016-01-06,372,C,0,1,QMXV11,"Based on observation and interview, the facility failed to maintain a clean area, free of debris, for 2 of 2 dumpsters observed. The findings included: Observation with the Certified Dietary Manager (CDM), on 1/4/16 at 9:45 AM, of the dumpster area revealed 2 dumpsters with trash on the ground including 4 disposable gloves turned inside out and assorted paper and plastic trash. Further review revealed 1 dumpster had an opened door. Interview with the CDM on 1/4/16 at 9:45 AM, of the dumpster area confirmed the facility failed to maintain the cleanliness of the dumpster area.",2019-01-01
5705,ASBURY PLACE AT KINGSPORT,445481,100 NETHERLAND LANE,KINGSPORT,TN,37660,2016-01-21,372,C,0,1,J5QA11,"Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris for 4 of 4 dumpsters observed. The findings included: Review of facility policy, Infectious and Hazardous Waste, revised 10/14 revealed .all garbage, trash and other non-infectious waste will be stored and disposed in a manner that will not permit the transmission of disease .providing a breeding ground for insects and rodents .constitute a safety hazard . Observation with the Certified Dietary Manager (CDM) on 1/19/16 at 10:55 AM, at the dumpster area revealed 4 dumpsters with trash on the ground including 3 disposable gloves, 2 tied plastic bags with contents, plastic spoons, 1 used bandage, straws, and other paper trash. Interview with the CDM on 1/19/16 at 11:00 AM, at the dumpster area confirmed the facility failed to maintain a clean dumpster area.",2019-01-01
5814,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2015-09-10,356,C,0,1,DGX811,"Based on review of nurse staffing, observation, and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 2 of 4 days reviewed for nurse staffing posted. The findings included: Review of the Daily Nurse Staffing Form dated 7/3/15 revealed staffing included 1 Registered Nurse (RN) for 7:00 AM to 7:00 PM. Review of a facility investigation revealed the RN on 7/3/15 had left the facility at a undetermined time and returned after lunch. Interview with RN #3 on 9/10/15 at 1:30 PM, in the Assistant Director of Nursing Office, confirmed the Daily Nurse Staffing dated 7/3/15 was not correct because the facility was unsure what hours the RN was on duty 7/3/15. Observation on 9/8/15 at 9:10 AM, outside the Nurse Administration Room, revealed the Daily Nurse Staffing Form dated 9/8/15 indicated there were 4 RNs on duty. Observation on all three units in the facility on 9/8/15 revealed 1 RN was on duty. Interview with the Director of Nursing (DON) on 9/8/15 at 1:00 PM, in the conference room, confirmed the Daily Nurse Staffing Form was incorrect and the facility had 1 RN on duty on 9/8/15.",2018-11-01
5877,MADISONVILLE HEALTH AND REHAB CENTER,445457,465 ISBILL RD,MADISONVILLE,TN,37354,2015-11-10,356,C,0,1,ZD7T11,"Based on observation and interview, the facility failed to post the current Daily Nurse Staffing information. The finding included: Observation on 11/8/15, at 9:20 AM, in the entrance wing, revealed the Daily Nurse Staffing was dated 11/6/15. Interview with Licensed Practical Nurse #2 at 11/8/15 at 9:40 AM, in the entrance wing, confirmed the facility failed to post the current Daily Nurse Staffing information.",2018-11-01
5939,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2015-08-12,161,C,0,1,FXQD11,"Based on review of the facility Surety Bond, resident trust fund accounts, and interview, the facility failed to ensure the Surety Bond covered the amount in the Resident Trust for 44 of 49 residents. The findings included: Review of the facility's Continuation Certificate (surety bond) revealed .beginning 2/1/15 and ending 2/1/16 .amount of $35,000.00 .shall not exceed in the aggregate (overall) the amount written . Review of the Resident Trust Statement dated 8/11/15, revealed the current balance was $41,276.92. Interview with the Business Office Manager (BOM) on 8/11/15 at 2:30 PM, in the BOM's Office, revealed the facility had been over the $35,000 limit on several occasions over the past 6 months according to the monthly statements. Interview with the Administrator on 8/11/15 at 9:00 AM, in the Administrator's Office, confirmed the Resident Trust Fund balance was currently over the $35,000.00 surety bond limit.",2018-11-01
6084,SIGNATURE HEALTHCARE OF CLARKSVILLE,445448,198 OLD FARMER ROAD,CLARKSVILLE,TN,37043,2015-07-09,356,C,0,1,9R4511,"Based on record review and interview, the facility failed to hold posted nurse staffing and census information for 18 months for the public to review upon request. The findings included: Review and interview of the Nurse Staffing/Census postings with the Staff Development Coordinator (SDC) on 7/6/15 revealed staffing postings for the last 18 months had not been kept. The SDC stated he/she had kept many of them, but they disappeared from his/her notebook. The SDC stated he/she started working in the facility in (MONTH) of this year and since that time staff filled out the posting forms daily, and then another staff person placed them in a book. The SDC stated the forms were missing, and he/she was not aware the postings had to be kept for 18 months. Interview on 7/8/15 at 11:36 P.M., the Administrator revealed he/she was not aware the nurse staffing and census forms had to be kept for 18 months. Interview on 7/8/15 at 4:08 P.M., the Director of Nurses (DON) stated he/she was aware the staffing and census forms were required to be kept for 18 months, and expected the assigned staff was keeping them according to the regulation. The DON acknowledged the facility staff did not keep the forms.",2018-10-01
6140,LIFE CARE CENTER OF OOLTEWAH,445511,5911 SNOW HILL ROAD,OOLTEWAH,TN,37363,2015-09-17,356,C,0,1,CDXL11,"Based on observation and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 1 of 5 days. The findings included: Observation on 9/13/15 at 9:00 AM, outside the conference room revealed the Posted Nurse Staffing sitting on a table dated 9/12/15. Interview with the Registered Nurse (RN) #11 on 9/13/15 at 9:35 AM, outside the conference room confirmed the Posted Nurse Staffing was incorrect.",2018-10-01
6187,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2015-06-03,167,C,0,1,QLMP11,"Based on observation and interview, the facility failed to provide the most recent state survey results in a readily accessible location for all residents in the facility. The findings included: Observation on 6/1/15, at 10:15 AM, of the facility's posting titled, State Survey Results, located in the glass display of the facility's lobby revealed Copies of the most recent State Survey can be found in the Lobby, East and West Nurses Station, the Dir (Director) of Nursing's office and Administrator's office . Observation on 6/1/15, at 10:15 AM, revealed the survey results could not be located in the lobby. Observation on 6/1/15, at 10:22 AM, revealed the survey results could not be located at the West Nurses Station. Interview with Licensed Practical Nurse #2 (LPN) on 6/1/15 at 10:25 AM, at the West Nurses Station, confirmed, The survey results are not here on the west station right now. Interview with LPN #1 on 6/1/15 at 10:29 AM, at the West Nurses Station, confirmed, There are no survey results in the lobby. Interview with LPN #2 on 6/1/15 at 10:38 AM, in the conference room, confirmed the state survey results were not located in the areas specified on the State Survey Result document located in the lobby.",2018-09-01
6238,PRINCETON TRANS CARE AT NORTH,445356,400 NORTH STATE OF FRANKLIN ROAD,JOHNSON CITY,TN,37601,2015-08-13,372,C,0,1,5QVH11,"Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris, for 1 of 1 dumpster reviewed. The findings included: Review of facility policy, Dumpster Cleaning Process, not dated revealed .rinse dumpster and area .pick up any remaining trash . Observation with the Dietary Director and the Patient Service Manager on 8/11/15 at 10:55 AM, at the 1 of 1 dumpster revealed on the outside of the dumpster the following: 1 empty plastic water bottle, 2 blue rubber gloves, a large plastic bag of trash, and other trash debris. Continued observation revealed a mixture of food debris and wet fluid under the dumpster flowing approximately 16 feet to the common driveway. Interview with the Dietary Director on 8/11/15 at 11:00 AM, at the dumpster confirmed .it's kind of nasty . Further interview confirmed the facility failed to maintain the cleanliness of the dumpster area.",2018-09-01
6273,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2015-06-18,159,C,0,1,XBDX11,"Based on policy review, review of residents' balances and interview, the facility failed to ensure residents receiving Medicaid funding balances did not exceeded the Supplemental Security Income (SSI) limit for 12 of 87 (Residents #19, 23, 33, 36, 47, 61, 66, 69, 76, 97, 98, and 100) residents with accounts in the facility during the first quarter of (YEAR) and for 14 of 87 (Residents #15, 23, 25, 36, 43, 57, 61, 63, 64, 66, 67, 69, 76, and 84) residents with accounts during the second quarter of (YEAR) as of (MONTH) 17, (YEAR), and the facility failed to provide a quarterly statement to a resident's (Resident #14) family member during the first quarter of (YEAR). The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, .5. At least every three months, the Facility shall furnish the Patient/Resident and other guardian, trustee, or conservator, if any, with a complete and verified statement of all funds and other property held by the Facility . 7. The Facility shall notify any Patient / Resident who receives Medicaid benefits when the amount in the Patient's / Resident's personal account reaches $200.00 less than the SSI resource limit for one person. This notice shall inform the Patient/Resident that if the amount in the account, in addition to the value of any of the Patient's/Resident's other non-exempt assets, reaches the SSI limit for one person, the Patient/Resident may become ineligible for Medicaid . 2. Review of the account balances as of 3/31/15 revealed the following balances: a. Resident #19 with a balance of $1,862.43 b. Resident #23 with a balance of $2, 728.66. c. Resident #33 with a balance of $1,900.80. d. Resident #36 with a balance of $1,963.52. e. Resident #47 with a balance of $2,134.12. f. Resident #61 with a balance of $2,408.73. g. Resident #66 with a balance of $2,407.47. h. Resident #69 with a balance of $3,481.04. i. Resident #76 with a balance of 18,153.05. j. Resident #97 with a balance of $2,453.24. k. Resident #98 with a balance of $5,483.71. l. Resident #100 with a balance of $10,944.00. 3. Review of the account balances as of 6/17/15 revealed the following balances: a. Resident #15 with a balance of $2,738.24. b. Resident #23 with a balance of $1,975.00. c. Resident #25 with a balance of $3,446.01. d. Resident #36 with a balance of $1,900.00. e. Resident #43 with a balance of $1,975.00. f. Resident #57 with a balance of $2,658.31. g. Resident #61 with a balance of $1,975.00. h. Resident #63 with a balance of $1,900.00. i. Resident #64 with a balance of $1,975.43. j. Resident #66 with a balance of $2,838.85. k. Resident #67 with a balance of $1,900.00. l. Resident #69 with a balance of $1,950.50. m. Resident #76 with a balance of $22,309.27. n. Resident #84 with a balance of $1,887.94. Interview with the Business Office Manager (BOM) on 6/17/15 at 1:38 PM, in the business office, the BOM was asked why residents had money in their accounts that exceeded the amount allowed. The BOM stated, One resident (#76) has a whole lot of money and I don't know why. The BOM verified that residents accounts exceeded the amount allowed per Medicaid. 3. Telephone Interview with Resident #14's mother on 6/15/15 at 5:31 PM, Resident #14's mother was asked, Does the facility give you a statement of how much money is in the resident's account? Resident #14's mother stated, No. I had not received a statement and she printed one out, and I haven't received any more statements. Interview with Business Office Manager (BOM) on 6/18/15 at 11:10 AM, in the business office, the BOM was asked when are statements mailed out. The BOM stated, Statements are mailed to the responsible party quarterly, the responsible party for Resident #14 is his mother and is who we send the statement to. Interview with BOM on 6/18/15 at 1:30 PM, in the conference room, the BOM brought in resident account statements from the last quarter from 1/1/15 to 3/31/15 and stated, I just found these in a filing cabinet stuffed in the back, I don't know if she (previous Business Office Manager) sent these out or not. Resident #14 was included in these statements.",2018-09-01
6274,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2015-06-18,160,C,0,1,XBDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of account balances, medical record review and interview, the facility failed to refund 4 of 4 (Residents #95, 120, 121 and 122) deceased residents' balances to the residents' estates. The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, 6. Upon the death of a Patient/Resident who has personal funds deposited with the Facility, such Patient/Resident funds will be conveyed within 30 days to the individual administering the Patient's/Resident's estate . 2. Medical record review revealed Resident #95 expired on [DATE]. Review of the Resident #95's account as of (MONTH) 17, (YEAR) revealed a balance of $1,168.82 that had not been refunded to Resident #95's estate. 3. Medical record review revealed Resident #120 expired on [DATE]. Review of Resident #120's account as of (MONTH) 17, (YEAR) revealed a balance of $1, 527.75 that had not been refunded to Resident #120's estate. 4. Medical record review revealed Resident #121 expired on [DATE]. Review of Resident #121's account as of (MONTH) 17, (YEAR) revealed a balance of $192.13 that had not been refunded to Resident #121's estate. 5. Medical record review revealed Resident #122 expired on [DATE]. Review of Resident #122's account as of (MONTH) 17, (YEAR) revealed a balance of $882.36 that had not been refunded to Resident #122's estate. 6. Interview with the Business Office Manager (BOM) on [DATE] at 1:38 PM, in the business office the BOM gave the surveyor an account balance report and stated, There are residents on here that have expired. The surveyor asked the BOM if Resident #120's funds had been refunded. The BOM stated, Not refunded yet. Interview with the BOM on [DATE] at 10:00 AM, in the business office, the BOM was asked if refunds had been made to Resident #95, 121 and 122. The BOM stated, No, not closed or refunded yet.",2018-09-01
6275,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2015-06-18,161,C,0,1,XBDX11,"Based on policy review, review of the Patient Care Interest Bearing statements and interview, the facility failed to ensure the Surety bond was sufficient to cover the amount of money in the resident trust account for 2 of 3 (April and (MONTH) (YEAR)) months reviewed. The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, .8. The Facility will purchase a surety bond or, as allowed by law, provide self-insurance to assure the security of all personal funds of Patients/Residents deposited with the Facility . 2. The Patient Care Interest Bearing bank statements documented the following: a. (MONTH) 1, (YEAR) through (-) (MONTH) 30, (YEAR): Daily ledger balance summary was $102,866.14. b. (MONTH) 1, (YEAR) - (MONTH) 31, (YEAR): Daily ledger balance summary was $131,545.79. Interview with the Business Office Manager (BOM) on 6/17/15 at 1:45 PM, in the business office, the BOM was asked if she was aware the average daily balance exceeded the facility's surety bond of $100,000.00. The BOM stated, Yes I noticed it when I printed it off and it's not covered.",2018-09-01
6361,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,356,C,0,1,E8N511,"Based on observation and interview, the facility failed to accurately post the daily nurse staffing data for 2 of 9 days observed. The findings included: Observation on 11/19/16 at 10:10 AM, in the lobby, revealed .Today's Staffing .Day shift .Night shift .Census 100 . Further review revealed the posted staffing was dated 11/18/16. Interview with Registered Nurse (RN) #6 on 11/19/16 at 10:35 AM, at the 300-400 nurses station, confirmed the posted staffing was dated 11/18/16 (1 day prior) and the facility .had not posted the nurse staffing sheet yet . Observation on 11/28/16 at 9:55 AM, in the lobby, revealed .Today's Staffing .Day shift .Night shift .Census 104 . Further review revealed the posted staffing was dated 11/23/16. Interview with RN #6 on 11/28/16 at 10:16 AM, in the lobby, confirmed the facility posted staffing was dated 11/23/16 (5 days prior) and the facility failed to post the current daily staffing.",2018-08-01
6406,"TRENTON HEALTH AND REHABILITATION CENTER, LLC",445308,2036 HIGHWAY 45 BYPASS,TRENTON,TN,38382,2015-05-06,356,C,0,1,8S8X11,"Based on observation and interview, the facility failed to ensure staffing information was posted on 3 of 3 (5/4/15, 5/5/15 and 5/6/15) days of the survey. The findings included: Observations revealed the staffing was not posted as followed: a. On 5/4/15 at 9:30 AM, 11:00 AM and 3:00 PM. b. On 5/5/15 at 7:30 AM, 10:30 AM, 2:00 PM and 5:00 PM. c. On 5/6/15 at 7:15 AM and 9:00 AM. Interview with the Director of Nursing (DON) on 5/6/15 at 9:50 AM, at the nurses station, the DON was asked where the staffing was posted. The DON stated, It's usually right there (pointing to an area on the wall across from the nurses station). The DON verified the staffing was not posted. Interview with the Assistant Director of Nursing (ADON) on 5/6/15 at 10:15 AM, in the conference room, the ADON was asked about posting of the staffing. The ADON stated, Typically it's posted every morning, just haven't done it this week.",2018-08-01
6478,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2015-02-04,371,C,0,1,ML4B11,"Based on policy review, review of the kitchen cleaning schedule and observation, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidenced by the presence of dark brown, gritty dust buildup under the edge of freezer #1 and failed to distribute food under sanitary conditions as evidenced by 2 of 2 staff members (Register Health Information Technician (RHIT) #1 and Certified Nursing Assistant (CNA) #1) entered the kitchen without a hair net. The facility has 92 of the 96 residents who receive a meal tray from the kitchen. The findings included: 1. Review of the facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .Sweep and spot mop after each meal and as needed; thorough mopping daily; scrubbing/brushing weekly . Review of the facility's kitchen cleaning schedule documented, .sweep, mop, clean and straighten . Observations in the kitchen on 2/2/15 at 10:28 AM and 2/3/15 at 7:50 AM, revealed the presence of dark brown, gritty dust buildup under the edge of freezer #1. 2. Observations in the kitchen on 2/3/15 at 10:14 AM, revealed RHIT and CNA #1 in kitchen area without a secured hair. Observations in the hall outside the kitchen on 2/4/15 at 9:31 AM, revealed signs PATIENTS RING BELL FOR SERVICE and DIETARY SERVICES. Observation revealed hair restraint covers available in the hall before entering the door to the kitchen area.",2018-07-01
6606,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2015-02-04,372,C,0,1,WR7L11,"Based on observation and interview, the facility failed to dispose of garbage properly to maintain sanitary conditions. The findings included: Observation of the garbage and refuse dumpster on February 4, 2015, from 8:05 a.m. until 8:10 a.m., revealed two of three garbage dumpsters had two lids open with black and white trash bags overstuffed and hanging out of the dumpsters. Interview with the Registered Dietician on February 4, 2015, at 8:10 a.m., in the dumpster area outside the laundry room entrance confirmed the lids were open, plastic bags of refuse were overstuffed, hanging out of the dumpsters, the lids were not closed, and refuse was not contained.",2018-05-01
6697,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2015-02-03,356,C,0,1,50D411,"Based on observation and interview, the facility failed to post current facility staffing. The findings included: Observation on February 1, 2015, at 9:43 a.m., in the hall adjacent to the AB Hall nurse's station revealed a wall-mounted staff posting sheet dated January 30, 2015. Interview with Registered Nurse #8 on February 1, 2015, at 9:45 a.m., in the hall in front of the AB Hall nurse's station, confirmed the staff posting was not the current date. Observation on February 1, 2015, at 9:48 a.m., in the hall adjacent to the CD Hall nurse's station revealed a wall-mounted staff posting sheet dated January 30, 2015. Interview with Licensed Practical Nurse #2 on February 1, 2015, at 9:50 a.m., in the hall in front of the CD Hall nurse's station, confirmed the staff posting was not the current date.",2018-05-01
6714,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2015-02-27,356,C,0,1,V17V11,"Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on February 23, 2015, at 7:35 a.m., in the facility front hall, revealed the nurse staffing sheet was dated February 20, 2015. Interview with Licensed Practical Nurse #2 on February 23, 2015, at 8:15 a.m., in the facility front hall, confirmed the nurse staffing sheet posted was not for the current date.",2018-05-01
6719,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2014-10-09,156,C,0,1,ZBLF11,"Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #26, #66 and 115) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 05-26-2014 . Telephone contact with the representative was made on 5/22/14. There is no documentation the telephone contact was confirmed by written notice on that same date. 2. Review of the Notice of Medicare Non-Coverage for Resident #66 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 08-14-14 . There is documentation with Resident #66's signature dated 8/18/14, four days after notification of Medicare Non-Coverage days. 3. Review of the Notice of Medicare Non-Coverage for Resident #115 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 06-06-2014 . Telephone contact with the representative was made on 5/22/14. There was no documentation the telephone contact was confirmed by written notice on that same date. 4. During an interview in the hallway on 10/8/14 at 6:30 PM, the Social Worker was asked to provide documentation where the Responsible Party had been notified in writing of the resident's Notice of Medicare Non-Coverage letter. The Social Worker stated, No, I do not have proof that I gave them a copy of the letter. The Social Worker was asked to verify the dates on Resident #66 Notice of Medicare Non-Coverage letter. The Social Worker stated, Oh, I can't believe I did that . I have the dates backward.",2018-05-01
6725,LIFE CARE CENTER OF JEFFERSON CITY,445275,336 WEST OLD ANDREW JOHNSON HWY,JEFFERSON CITY,TN,37760,2015-03-10,356,C,0,1,W72C11,"Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on March 8, 2015, at 8:55 a.m., at the entrance hallway revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for Saturday, March 7, 2015, and had not been updated to reflect current nursing staff in the facility on March 8, 2015. Interview with the Licensed Practical Nurse #3, at the time of the observation on March 8, 2015, confirmed the staffing information did not reflect the current nursing staff present and confirmed the facility failed to post accurate staffing.",2018-05-01
6726,REELFOOT MANOR HEALTH AND REHAB,445285,1034 REELFOOT DRIVE,TIPTONVILLE,TN,38079,2015-01-15,244,C,0,1,T0F711,"Based on policy review, review of the resident council minute reports and interview, it was determined the facility failed to promptly resolve grievances related to residents not getting coffee before the meal trays as documented in the minutes for 3 of 3 (October, November and December 2014) months of minutes reviewed. The findings included: 1. Review of the facility's residents' rights policy documented, .(f) Grievances. A resident has the right to-- (1) Voice grievances . (2) Prompt efforts by the facility to resolve grievances the resident may have . Review of the facility's filing grievances / complaints policy documented, .5. Upon receipt of a grievance and/or complaint, the Social Worker will investigate the allegations and submit a written report of such findings the Administrator within (5) working days of receiving the grievance and/or complaint . 6. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken . 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility . 2. Review of the October 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 3. Review of the November 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 4. Review of the December 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 5. During an interview in the Social Service office on 1/13/15 at 8:46 AM, the Human Resource Director was asked about the facility's response to the council's problem with getting the coffee before the trays. The Human Resource Director stated, .(named Director of Nursing (DON)) has addressed that and a Certified Nursing Assistant (CNA) has been assigned to pass out the coffee. It is being addressed. 6. During an interview in Resident #34's room on 1/14/15 at 3:19 PM, Resident #34, president of the resident council, was asked if there were any concerns the resident council had. Resident #34 stated, Yeah, we want out coffee before the trays. We told the old DON and dietary has been to the meetings. We were told if the coffee cart comes out first we can have the coffee before trays, but if coffee tray comes out after trays we get it after and the coffee is cold. 7. During an interview in the DON's office on 1/15/15 at 10:53 AM, the DON was asked about the council's grievances. The DON stated, I have not been to one of the meetings yet. Yes, I was told about the coffee. I went to them in December and I have someone, (may be a CNA or a Nurse) whoever gets finished first to pass the coffee cart around. The DON was asked would you expect grievances to be addressed sooner than 3 months. The DON stated, Yes.",2018-05-01
6761,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2014-11-06,170,C,0,1,GMT011,"Based on policy review and interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays for 82 of 82 residents residing in the facility. The findings included: Review of the facility's Resident Rights policy documented, .The Resident has the right to privacy in written communication, including the right to send and receive mail promptly . During an interview in Resident #96's room on 11/5/14 at 10:15 AM, alert and oriented Resident #96 was asked if residents receive mail on Saturday. Resident #96 stated, No, I don't. During an interview at the receptionist's desk on 11/5/14 at 10:30 AM, the Business Office Manager (BOM) was asked if the mail is delivered on Saturday. The BOM stated, Here is the problem, there is a manager here until 12 on Saturday and if the mail is delivered after 12 there is no manager here to give the residents' their mail. Now if we have a fill in postman he is scared there is no manager here so he will not stop and will save the mail until Monday.",2018-05-01
6832,PARIS HEALTH CARE NURSING & REHABILITATION CTR,445462,800 VOLUNTEER DRIVE,PARIS,TN,38242,2015-01-22,372,C,0,1,BH6311,"Based on observation and interview, it was determined the facility failed to ensure proper garbage disposal as evidenced by garbage on the ground around the outside storage receptacles on 3 of 3 (1/20/15, 1/21/15 and 1/22/15) days of the survey. The findings included: Observations at the garbage dumpsters on 1/20/15 at 10:10 AM, on 1/21/15 at 4:00 PM and on 1/22/15 at 9:10 AM, revealed a pile of dried leaves, several cigarettes butts, 3 plastic food lids, 1 small piece of broken glass, 1 french fry and several pieces of small paper laying outside the dumpster. During an interview at the dumpsters on 1/20/15 at 10:15 AM, the certified dietician manager (CDM) was asked how often the garbage is picked up. The CDM stated, Monday, Wednesday and Friday. The CDM was then asked would you expect the dumpsters to look like this. The CDM stated, I wouldn't expect it. During an interview at the dumpsters on 1/22/15 at 9:15 AM, the Maintenance man was asked if he was in charge of the dumpsters. The maintenance man stated, Yes. The maintenance man was shown the cigarette butts, plastic food lids, dried leaves, a small piece of broken glass, food particles and other trash around the 2 dumpsters and was asked when the last time the dumpster area had been cleaned. The maintenance man stated, Three months ago. The maintenance man was asked if the dumpsters should look like that. The maintenance man stated, We all have dropped the ball. During an interview in the dining room on 1/22/15 at 9:22 AM, the housekeeping supervisor (HS) was asked should there be cigarette butts, plastic food lids, dried leaves, small pieces of broken glass around the dumpsters. The HS stated, Probably not. It will be took care of. During an interview in the conference room on 1/22/15 at 4:43 PM, the Administrator was asked if it was acceptable for trash to be around the dumpsters. The Administrator stated, No ma'am. Should be inside the dumpsters.",2018-05-01
6919,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2015-01-22,356,C,0,1,YJLF11,"Based on observation and interview, the facility failed to ensure the Nurse Staffing data posted was correct. The findings included: Observation on January 20, 2015, at 11:00 a.m., on the main hall, revealed the Nurse Staffing posted listed nine Licensed Practical Nurses (LPNs) were working on the day shift. Interview on January 20, 2015, at 11:15 a.m., with the Assistant Director of Nursing, on the main hall, confirmed there were only four LPNs working the day shift and confirmed the posted Nurse Staffing was not correct.",2018-04-01
7006,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-08-12,356,C,0,1,FK2C11,"Based on observation and interview, the facility failed to post the nurse staffing data. The findings included: Observation on August 10, 2014, at 11:00 a.m. and at 11:30 a.m., in the hallway outside the Administrator's office, revealed the nurse staffing data was not posted. Interview with the Administrator, on August 10, 2014, at 11:30 a.m., at the nurse staffing posting site, revealed .we know the staff posting is missing, we're still working on it . Interview with the Director of Nursing (DON) and the Staffing Coordinator, on August 10, 2014, at 2:53 p.m., in the DON's office, confirmed the nurse staffing data had not been posted Saturday, August 9, 2014, or Sunday, August 10, 2014. Further interview revealed it was the responsibility of the Staffing Coordinator to prepare the posting.",2018-03-01
7123,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2014-10-16,356,C,0,1,TZQW11,"Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on October 13, 2014, at 8:55 a.m., in the front hallway, revealed the nursing staff information posted was for the nursing staff scheduled on October 10, 2014, and had not been updated to reflect the current nursing staff in the facility for October 13, 2014. Interview with the Administrator on October 13, 2014, at 8:55 a.m., in the front hallway, confirmed the nurse staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate nurse staffing.",2018-03-01
7435,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2014-10-14,372,C,0,1,VRPY11,"Based on observation and interview, the facility failed to maintain the garbage storage area in a clean manner, free of debris, for one of one kitchen dumpster areas observed. The findings included: Observation on October 12, 2014, at 11:00 a.m., around the dumpster area outside of the facility, revealed the dumpster had no cover and several bags of garbage were overflowing from the dumpster onto the ground surrounding the dumpster. Observation of the dumpster on October 13, 2014, at 3:25 p.m., revealed the dumpster did not have a cover to discourage pests or vermin. Interview with the Dietary Manager on October 13, 2014, at 3:26 p.m., in the dumpster area, confirmed there had been several bags of garbage laying on the ground on October 12, 2014, and the dumpster did not have a cover.",2017-12-01
7543,CREEKSIDE HEALTH AND REHABILITATION CENTER,445516,306 W DUE WEST AVE,MADISON,TN,37115,2015-02-25,356,C,0,1,GXV511,"Based on observation and interview, the facility failed to post accurate nurse staffing information. The findings included: Observation on February 23, 2015, at 6:20 a.m., at the first floor hallway, revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed, the staffing information posted was the staff scheduled for Thursday, February 19, 2015, and had not been updated to reflect current nursing staff in the facility on February 23, 2015. Interview with the charge nurse at the time of the observation on February 23, 2015, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate staffing.",2017-12-01
7866,DICKSON HEALTH AND REHAB,445477,901 N CHARLOTTE,DICKSON,TN,37055,2014-03-26,356,C,0,1,ZJWR11,"Based on observation and interview, it was determined the facility failed to post nurse staffing information on a daily basis at the beginning of each shift on 3 of 3 (3/24/14, 3/25/14, and 3/26/14) days of the survey. The findings included: Observations in the front lobby and throughout the facility on 3/24/14 at 9:50 AM, on 3/25/14 at 10:30 AM, and on 3/26/14 at 11:25 AM, revealed no nurse staffing information was posted. During an interview in front of the east hall nurses' station on 3/26/14 at 11:30 AM, Nurse #1 was asked where they posted the nurse staffing information for each shift. Nurse #1 turned and pointed to the wall across from the east hall nurses' station and stated, It used to be right here. During an interview in the activity room on 3/26/14 at 3:30 PM, the Human Resources Director was asked where they posted the nurse staffing information for each shift. The Human Resources Director stated, They took it down when they started painting about 3 months ago. I guess they haven't posted it since.",2017-10-01
7957,HILLVIEW COMMUNITY LIVING CENTER,445367,"897 EVERGREEN STREET, PO BOX 769",DRESDEN,TN,38225,2014-02-20,167,C,0,1,TF2P11,"Based on observation and interview, it was determined the facility failed to ensure survey results were readily accessible to the residents residing in the facility. The findings included: Observations on 2/20/14 at 7:30 AM revealed a sign posted that documented, Survey results located at Nursing Station, Social Director Office and Administrator Office. Observations at the nurses' station revealed no evidence of the survey results. During an interview at the nurses' station on 2/20/14 at 7:35 AM, Nurse #1 was asked where the survey results were located. Nurse #1 stated, Survey results are kept here. The book is always up here (indicating the top shelf of the medical record rack located inside the nurses station.) Nurse #1 was observed to locate the book containing the survey results on the top shelf of the medical record rack located inside the nurses' station. The survey results were not readily accessible to residents. During an interview in the conference room on 2/20/14 at 9:00 AM, the Administrator was asked where the location of the survey results were. The Administrator stated, Survey results are at the nurses' station and in my office . there is a sign posted out here in the hallway . the survey book is suppose to be laying on the counter at the nurses' station. During an interview in the Resident Council President's room on 2/20/14 at 10:10 AM, the Resident Council President was asked if the results of the state inspection was available to read. The Resident Council President stated, Have to ask if want to see them. On 2/20/14 at 9:10 AM in the conference room the Administrator confirmed the survey results were not on the counter at the nurses' station. The Administrator stated, We have moved the survey book to the fireplace . will change the notice.",2017-09-01
8014,LIFE CARE CENTER OF RHEA COUNTY,445494,10055 RHEA COUNTY HIGHWAY,DAYTON,TN,37321,2014-08-20,167,C,0,1,HN4Z11,"Based on observation and interview, the facility failed to make the survey results readily accessible and failed to post a notice of their availability. The findings included: Observation on August 18, 2014, at 9:03 a.m., in the lobby areas, revealed a black notebook located in an enclave to the right of the front entrance, not visible from the front entrance, containing the survey results. Continued observation revealed no sign was posted in the facility identifying the location of the survey results. Interview with the Administrator on August 19, 2014, at 9:31 a.m., in the facility front lobby, confirmed the facility failed to place the survey in a readily accessible place and failed to post a notice of the availability of the survey results.",2017-09-01
8100,LYNCHBURG NURSING CENTER,445279,40 NURSING HOME ROAD,LYNCHBURG,TN,37352,2014-01-28,170,C,0,1,FFT711,"Based on interviews, it was determined the facility failed to ensure residents received their mail within 24 hours of delivery to the post office for 53 of 53 residents residing in the facility. The findings included: During an interview in Resident #66's room on 1/28/14 at 2:00 PM, Resident #66 was asked if mail is received unopened and on Saturdays. Resident #66 stated, We do not get mail on Saturdays. I don't know why . would like to get mail on Saturdays . I love getting mail . During an interview in the Administrator's office on 1/28/14 at 2:20 PM, the Administrator was asked if mail was delivered to the residents on Saturdays. The Administrator stated, No . the mail is delivered to a post office box . we have to pick it up . we receive mail for the entire facility and we only have one key . so mail does not get misplaced, lost . sometimes have checks . business mail .",2017-08-01
8176,GOOD SAMARITAN SOCIETY - FAIRFIELD GLADE,445506,100 SAMARITAN WAY,CROSSVILLE,TN,38558,2014-05-30,159,C,0,1,S1EI11,"Based on observation, review of resident trust fund accounts, and interview, the facility failed to ensure residents had ready access to their personal funds for nine of nine residents with trust accounts. The findings included: Observation on May 27, 2014, at 10:04 a.m., revealed a sign on the front facility admission desk stating resident trust accounts are accessable .Monday through Friday from 8:00 am to 4:00 pm. Review of resident trust accounts and interview with the Admission Assistant on May 29, 2014, at 10:47 a.m., in the Assistant's office, confirmed resident personal funds are not available outside normal business hours of 8:00 a.m. to 4:00 p.m., as the sign stated.",2017-08-01
8203,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2014-04-23,356,C,0,1,B1M711,"Based on Review of the POS [REDACTED]. The findings included: Observation on April 21, 2014, at 8:30 a.m., of the posted nurse staffing data revealed there were four Registered Nurses on duty and eight Licensed Practical Nurses. Interview with the Director of Nursing on April 21, 2014, at 9:05 a.m., in the hallway, revealed there were only three Registered Nurses on duty and seven Licensed Practical Nurses, and confirmed the nurse staffing data was not correct.",2017-08-01
8367,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2014-03-26,356,C,0,1,844O11,"Based on observation and interview, the facility failed to post nurse staffing data daily prior to the beginning of each shift. The findings included: Observation on March 24, 2014, at 5:35 a.m., revealed the nurse staffing data posted was dated March 21, 2014. Observation and interview on March 24, 2014, at 5:40 a.m., with the Assistant Director of Nursing, in the front hallway confirmed the current nurse staffing data was not posted.",2017-07-01
8379,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2014-04-02,252,C,0,1,R5JB11,"Based on observation and interview, the facility failed to provide a homelike environment by serving the resident's meals on trays, in two of five dining areas. The findings included; Observation on March 31, 2014, at 11:55 a.m., in the H&I dining area revealed the resident's lunch meals were served on food trays. Interview with Activities Coordinator, on March 31, 2014, at 11:55 a.m., at the H&I nurse's station confirmed the resident's lunches were served on food trays. Further observation on April 1, 2014, at 7:45 a.m., in the J&K dining area revealed the resident's breakfast meals were served on food trays. Interview with Licensed Practical Nurse #1, on April 1, 2014, in the J&K dining area at 7:45 a.m., confirmed, We always keep food on trays, it's all there for them.",2017-07-01
8415,"NHC HEALTHCARE, SEQUATCHIE",445126,"360 DELL TRAIL, PO BOX 878",DUNLAP,TN,37327,2014-02-26,494,C,0,1,FUDF11,"Based on review of the CFR Title 42, Volume 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs) and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, .Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program . Interview with the Nurse Aide Training (NAT) Instructor on February 26, 2014, at 9:30 a.m., in the instructor's office, confirmed the facility required each student to pay $80.00 for class materials. Telephone interviews on February 26, 2014, at 9:45 a.m., and 10:40 a.m., with two former NAT students who completed the facility's NAT class offered in January 2014, and currently employed by the facility, confirmed the facility had charged each student $80.00 for class materials. Review of the facility's NAT class records from 2013, and January 2014, revealed the facility currently had fourteen former NAT students employed at the facility, and all fourteen had been charged $80.00 for class materials. Interview with the Administrator on February 26, 2014, at 10:45 a.m., at the Social Worker's office, confirmed the facility had not reimbursed nurse aides for the cost of the class after the nurse aides completed the class and were employed by the facility.",2017-06-01
8446,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2013-11-21,167,C,0,1,WI9611,"Based on observation and interview, it was determined the facility failed to ensure the survey results were placed in a location readily accessible for the residents and failed to post a notice for the location of the results in a location convenient for the residents and public. The facility census was 91 residents. The findings included: Observations on the administrative hall on 11/19/13 at 3:50 PM and 11/20/13 at 4:05 PM, revealed a document posted on an information board that contained a paragraph regarding the location of the survey results. The paragraph documented survey results were located in a blue notebook in the right hand drawer of one of the tables in the front lobby. During an interview in Resident #50's room on 11/20/13 at 3:40 PM, Resident #50, the Resident Council Vice-President, was asked if survey results were available to read without having to ask for them. Resident #50 stated, .if you asked. During an interview at the 100 hall nurses' station on 11/21/13 at 10:00 PM, the Director of Nursing (DON) was asked about the accessibility of the survey results. The DON stated, It (written notice) is on the bulletin board where to find them from the main lobby. The DON was asked if there is a sign in the lobby stating where to find the survey results. The DON stated, No.",2017-06-01
8497,LIFE CARE CENTER OF RED BANK,445240,1020 RUNYAN DR,CHATTANOOGA,TN,37405,2014-05-21,372,C,0,1,FL2P11,"Based on observation and interview, the facility failed to maintain sanitary conditions for two of two dumpsters in the garbage dumpster area. The findings included: Observation on May 19, 2014, at 2:30 p.m., in the dumpster area, revealed the doors to the facility dumpsters closed. Continued observation revealed multiple used latex gloves and medication dispensing cups scattered on the ground throughout the dumpster area. Continued observation revealed a plastic urinal on the ground beside the dumpster. Interview with the Dietary Manager on May 19, 2014, at 2:35 p.m., in the dumpster area, confirmed the waste was to have been contained inside the dumpsters and the facility failed to maintain sanitary conditions in the dumpster area.",2017-06-01
8506,LIFE CARE CENTER OF CENTERVILLE,445252,112 OLD DICKSON RD,CENTERVILLE,TN,37033,2013-12-11,170,C,0,1,D73511,"Based on policy review and interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays for 77 of 77 residents residing in the facility. The findings included: Review of the facility's Activity & (and) Recreation Services Manual policy documented, .Mail delivered Six days a week . During an interview in Resident #42's room on 12/11/13 at 7:48 PM, Resident #42 was asked if the mail is delivered on Saturdays. Resident #42 stated, .7 to 8 months ago it was almost everyday . During an interview in the activities room on 12/11/13 at 6:50 PM, the Activity Director (AD) was asked if the residents received mail on Saturdays. The AD stated, They get their mail Monday through Friday but not on Saturday. The AD was then asked if the post office is open on Saturday. The AD stated, Yes, it is till (until) noon .",2017-06-01
8542,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2013-09-05,170,C,0,1,XY9R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review and interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays for 57 of 57 residents residing in the facility. The findings included: Review of the facility's Mail policy documented, .4. Mail will be delivered to the resident within twenty-four (24) hours of arrival in this facility, and the resident's out-going mail will be delivered to the postal service within twenty-four (24) hours, except on weekends and holidays . During the resident council member interview in Resident #9's room on 9/4/13 at 4:45 PM, Resident #9 was asked, Is mail delivered unopened and on Saturdays? Resident #9 stated, No, she (Social Worker) ain't here on Saturdays . During an interview in the Social Service's office on 9/4/13 at 5:30 PM, the Social Worker was asked if mail was delivered to residents on Saturdays. The Social Worker stated, The postman does not deliver here on Saturdays . During an interview via telephone on 9/5/13 at 8:20 AM, the letter carrier at the United States Postal Service was questioned if mail is delivered to this facility on Saturdays. The letter carrier stated, I have delivered to the nursing home for [AGE] years and the administration has always said not to deliver the mail on Saturdays because they are not there. I know the nursing home is open 24 hrs 7 days a week .",2017-06-01
8549,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2013-09-05,356,C,0,1,XY9R11,"Based on observation and interview, it was determined the facility failed to post nurse staffing information on a daily basis at the beginning of each shift on 3 of 3 (9/3/13, 9/4/13 and 9/5/13) days of the survey. The findings included: Observations on the B hall bulletin board on 9/3/13 at 9:30 AM, on 9/4/13 at 8:00 AM and on 9/5/13 at 9:15 AM, revealed the nurse staffing posted for all three shifts, not just the current shift as required. During an interview in the conference room on 9/5/13 at 9:15 AM, Nurse #2 was asked why she posted the staffing for all three shifts ahead of time. Nurse #2 stated, That is the way it runs . If someone calls in, I replace them. That is just the way it runs . I have done this for a year .",2017-06-01
8559,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2014-02-20,356,C,0,1,BTQK11,"Based on observation and interview, the facility failed to post nurse staffing information. The findings included: Observation and interview, on February 18, 2014, at 10:20 a.m., with the Assistant Director of Nursing, at the nursing station, confirmed the nurse staffing information was not posted.",2017-06-01
8624,SOUTHERN TENN MEDICAL CENTER SNF,445222,629 HOSPITAL ROAD,WINCHESTER,TN,37398,2014-02-12,356,C,0,1,L4F711,"Based on observation and interview, the facility failed to post nurse staffing information. The findings included: Observation on February 10, 2014, at 10:10 a.m., revealed the nurse staffing information was not posted. Interview on February 10, 2014, at 10:30 a.m., with Registered Nurse #1, in the hallway, confirmed the nurse staffing information for February 10, 2014, was not posted.",2017-05-01
8625,SOUTHERN TENN MEDICAL CENTER SNF,445222,629 HOSPITAL ROAD,WINCHESTER,TN,37398,2014-02-12,372,C,0,1,L4F711,"Based on observation, facility policy review, and interview, the facility failed to maintain the dumpster area appropriately. The findings included: Observation of the dumpster on February 10, 2014, at 1:55 p.m., with the Dietary Manager, revealed a one gallon open container of mayonaise open inside the dumpster, and the dumpster area had the following debris in the area around the dumpster: soiled gloves; an aluminum lid; paper; cardboard debris; and a plastic water bottle. Review of the faciliity's policy Trash and Grease removal, revised August 2013, revealed .All trash must be in plastic trash bags . Interview with the Dietary Manager, on February 10, 2014, at the time of the observation, confirmed the dumpster area was not properly maintained.",2017-05-01
8658,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2014-02-05,356,C,0,1,ZHJ911,"Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on February 3, 2014, at 10:25 a.m., in the main lobby, revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed, the staffing information posted was the staff scheduled for Sunday, February 2, 2014, and had not been updated to reflect current nursing staff in the facility on February 3, 2014. Interview with Licensed Practical Nurse #2 at the time of the observation on February 3, 2014, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate staffing.",2017-05-01
8713,PARIS HEALTH CARE NURSING & REHABILITATION CTR,445462,800 VOLUNTEER DRIVE,PARIS,TN,38242,2013-08-27,356,C,0,1,O0OO11,"Based on observation and interview, it was determined the facility failed to ensure the total number and the actual hours worked were posted as required for 3 of 3 (June, July and August 2013) months reviewed. The findings included: Observations in the private dining room on 8/27/13 at 4:00 PM, revealed the facility's Daily Nurse Staffing for June, July and August, 2013 did not post totaled actual hours worked. During an interview in the private dining room on 8/27/13 at 4:00 PM, Nurse #7 was asked if the nursing hours are posted. Nurse #7 stated, .he (the Administrator) just gave me an inservice today . I didn't know I was supposed to post the hours. I have only been doing this job for a short period of time . During an interview in the private dining room on 8/27/13 at 4:10 PM, the Administrator verified the hours were not posted as required.",2017-05-01
8715,AVE MARIA HOME,445490,2805 CHARLES BRYAN RD,BARTLETT,TN,38134,2013-08-21,170,C,0,1,HRON11,"Based on interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays for 75 of 75 residents residing in the facility. The findings included: During an interview in Administrator's office on 8/21/13 at 5:00 PM, the Administrative Assistant stated, Mail is delivered here on Saturdays to the front desk and it is placed in my office and on Mondays I put it (mail) in the Activities Box and they distribute it (mail) out to the residents . During an interview in the activities department office on 8/21/13 at 5:15 PM, the Activities Director confirmed that no mail was delivered to the residents on Saturdays.",2017-05-01
8721,MCKENDREE VILLAGE INC,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2014-02-05,372,C,0,1,U6BO11,"Based on observation and interview, the facility failed to ensure garbage and refuse was properly disposed of. The findings included: Observation on February 4, 2014, at 9:50 a.m., with the Dietary Executive Chef and the Administrator, at the dumpsters behind the kitchen revealed three dumpsters with a large amount of refuse including uneaten food, empty beverage containers, empty food containers, and an unidentified brownish red substance inside of a plastic covering the ground surrounding the dumpsters. Interview with the Dietary Executive Chef at the time of the observation confirmed the facility had failed to ensure the garbage and refuse was disposed of properly.",2017-05-01
8749,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,494,C,0,1,S0XG11,"Based on review of the CFR Title 42, Volumn 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs) and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, .Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program . Interviews with three Nurse Aide Trainees (NAT) currently enrolled in the NAT class provided by the facility on January 23, 2014, from 10:05 a.m., to 10:10 a.m., in the conference room, revealed each trainee had been required to pay $225.00 for class materials and training. Interview with the Staff Education Coordinator on January 23, 2014, at 10:10 a.m., in the Staff Education Coordinator's office, confirmed the NAT students were not employed during the training, and the charge for the class was $225.00 for the training and materials. Continued interview confirmed the Staff Education Coordinator had no knowledge of persons who had been hired by the facility after completing the class being reimbursed for the cost of the class. Interview with NAT #1 on January 23, 2014, at 10:40 a.m., in the conference room, confirmed the nurse aide had been enrolled in the class that started October 7, 2013, and was hired by the facility on October 30, 2013. Continued interview confirmed NAT #1 had not been reimbursed by the facility for the NAT class. Interview with the Administrator in the Administrator's office on January 23, 2014, at 10:45 a.m., confirmed the facility had not reimbursed nurse aides for the cost of the class after the nurse aides completed the class and were employed by the facility.",2017-04-01
8787,KINDRED NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2014-01-30,356,C,0,1,66U611,"Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on January 27, 2014, at 5:28 a.m., at the unit 2 nurse's station revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted nurse staffing revealed the staffing information posted was the staff scheduled for Friday, January 24, 2014, and had not been updated to reflect current nurse staff in the facility on January 27, 2014. Interview with License Practical Nurse #2 at the time of the observation on January 27, 2014, confirmed the staffing information did not reflect the current nurse staff present and confirmed the facility had failed to post accurate staffing.",2017-04-01
8972,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2013-12-04,372,C,0,1,VL8511,"Based on observation and interview, the facility failed to properly contain refuse in and around the dumpster. The findings included: Observation with the Certified Dietary Manager (CDM) on December 2, 2013, at 9:50 a.m., revealed there were gloves, paper debris, broken glass, cigarette butts, and food debris on the ground near the dumpster area and an open bag of trash with food spillage inside the dumpster. Interview with the CDM, at the time of the observation, revealed the odor inside the dumpster was stinky and confirmed the dumpster and the area surrounding the dumpster was not properly maintained.",2017-03-01
8983,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2013-10-10,161,C,0,1,F4M111,"Based on review of facility records and interview, the facility failed to provide a Surety Bond to at least equal the residents' personal funds balance. The findings include: Review of the balance sheet for the residents' personal funds dated September 30, 2013, revealed a total balance of $69,209.44. Review of a facility letter from the insurance company dated August 17, 2013, revealed a surety bond amount of $35,000.00 with the effective date of November 15, 2005. Interview with the Billing Administrator on October 9, 2013, at 3:00 p.m., in the front office, confirmed the facility failed to ensure a surety bond at least equal to the residents' funds balance.",2017-03-01
8989,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2013-10-10,494,C,0,1,F4M111,"Based on review of the CFR Title 42, Volumn 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs), review of the facility Nurse Aide Training Program, review of personnel files, review payroll register, and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, .Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program . Review of the Nurse Aide Training (NAT) Program with the Assistant Director of Nursing (ADON) in the ADON office on October 10, 2013, at 7:25 a.m., revealed the facility conducted the most recent NAT class in August 2013. Review of the personnel files for Nurse Aides #1, #2, and #4, revealed a signed and dated document titled C.N.A. Classes. Review of the document revealed, C.N.A. (Certified Nursing Assistant) classes are offered at a cost of $300.00. You must be employed at least 6 months full-time after being certified with Mabry Health & Rehab Center for these fees to be waived. If you quit or are terminated due to an unsatisfactory probationary period prior to 6 months of employment, you will be required to pay for your class. I agree to have this fee taken out of my paycheck. You have to work full-time also. Review of the personnel files of Nurse Aides #1 and #2 revealed they were in the most recent NAT class. Review of the files revealed the document titled C.N.A. Classes were signed and dated August 16, 2013. Review of the personnel file for aide #4 revealed the document was signed and dated June 21, 2013. Continued review revealed each of the nurse aides were full-time employees of the facility. Review of the facility's payroll register period ending July 31, 2012, revealed $300.00 was deducted from Nurse Aide #7's payroll check for educational fee. Review of the facility's payroll register period ending August 31, 2012, revealed $300.00 was deducted from Nurse Aide #8's payroll check for educational fee. Interview with CNA #1 in the A Hall on October 9, 2013, at 1:11 p.m., revealed, I am not sure if they take the money out of my check for the class or not .I know I have to pay for the class if I get fired or quit before 6 months. Interview with the NAT Program Instructor/ADON in the ADON office on October 10, 2013, at 7:35 a.m., revealed the Nurse Aides were required to work for six months after the class or were charged for the class because they would come to this class and then go work somewhere else. Interview with the Human Resources employee in the administrative office on October 10, 2013, at 9:20 a.m., revealed the facility had charged both employees and non-employees for the NAT class. Continued interview confirmed Nurse Aide #7 and #8 were employees of the facility and attended the facility's NAT program, and did not stay for 6 months after class. Continued interview revealed, We have charged them if they quit before 6 months of employment .we take it out of their last check .we have not done it since we found out we were not supposed to .in April. Continued interview confirmed the contract to be charged for the class was signed by the Nurse Aides in August, and confirmed the facility failed to ensure the Nurse Aides were not charged for the program.",2017-03-01
8991,BEECH TREE MANOR,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2013-11-14,494,C,0,1,ZNZK11,"Based on review of the CFR Title 42, Volumn 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs), review of the facility Nurse Aide Training Program, and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, .Sec. 483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program . Interview with Certified Nursing Aide (CNA) #1 on November 12, 2013, at 2:30 p.m., in the facility's lobby, revealed CNA #1 had to pay for the book for the class taken October 14, 2013 through October 25, 2013. (Most recent class.) Interview with Staff Development Coordinator (CNA program coordinator) on November 12, 2013, at 2:40 p.m., in the conference room, confirmed the facility charged the students for the materials for the Nurse Aide Training Program. Interview with the Administrator on November 14, 2013, at 2:00 p.m., in the administrator's office, confirmed the facility charged for the books for the class due to the expense of the materials.",2017-03-01
9006,FORT SANDERS TCU,445328,1901 CLINCH AVE,KNOXVILLE,TN,37916,2013-12-04,371,C,0,1,BEXG11,"Based on observation and interview, the facility failed to store food and equipment in a sanitary manner. The findings included: Observation on December 2, 2013, at 9:15 a.m., in the kitchen, revealed four pans of prepared Jello, cut in cubes, in refrigrator #1, labeled .date prepared November 23, 2013 .expiration date November 26, 2013 . Continued observation revealed an additional four pans of prepared Jello, in refrigrator #2, labeled .date prepared November 23, 2013 .expiration date November 26, 2013 . Review of facility policy, Food and Suppy Storage Procedures, last revised January, 2012, revealed .cover, label and date unused portions and open packages .use the (named facility's) orange label .complete all sections on the label . Inteview with the contractor's Dietary Manager (DM) on December 2, 2013, at 9:15 a.m., in the kitchen, revealed .the Jello in refrigrator #2 was prepared today (December 2, 2013) .they did not change the label and reused the plastic wrap covering . Continued interview with the DM confirmed the pans of Jello had expired on November 26, 2013, and were avalible for serving to the patients. Observation on December 3, 2013, at 10:10 a.m., in the clean diswashing area, revealed one fan hanging on the wall, in the on position, blowing directly on the clean area where the food trays are stored. Continued observation revealed dirty trays and food containers from the cafeteria, in the same area where the clean food trays were stored, and the fan blowing on the dirty and clean areas. Inteview with the DM on December 3, 2013, at 10:10 a.m., in the clean dishwashing area of the kitchen, confirmed the fan was blowing on the clean and dirty areas in the kitchen.",2017-03-01
9092,HILLVIEW HEALTH CENTER,445464,1666 HILLVIEW DRIVE,ELIZABETHTON,TN,37643,2014-01-23,161,C,0,1,5HVZ11,"Based on review of the Trial Balance form for the resident trust accounts, the facility failed to ensure the Patient Fund Bond (surety bond) was sufficient to cover the amount of money in the resident trust account for nine of nine residents with resident trust accounts. The findings included: Review of the Trial Balance form dated January 23, 2014, revealed there were nine residents with trust fund accounts with a total of thirteen thousand, three hundred, thirty-nine dollars,and eight cents ($13,339.08). Review of the Patient Fund Bond revealed the bond amount was ten thousand dollars ($10,000.00). Interview on January 23, 2014, at 9:25 a.m., with the Business Office Manager and the Administrator, in the Administrator's office, confirmed the Patient Fund Bond was not sufficient to cover the amount of money in the resident trust account.",2017-03-01
9117,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2013-11-19,161,C,0,1,U5R111,"Based on review of the facility's Long Term Care Facility Resident Fund Bond and review of the facility Aging Report balance, the facility failed to ensure the Surety Bond was greater than or equal to the amount of the combined resident funds. The findings included: Review of the facility Surety Bond revealed the bond was for a maximum amount of ten thousand dollars ($10,000.00). Review of the facility Aging Report (report with the combined resident trust total) revealed the combined total ending balance of the residents' trust accounts was $12,259.24. Interview with the Business Office Manager on November 18, 2013, at 12:51 p.m., in the Business Office, confirmed the facility failed to ensure the Surety Bond was greater than or equal to the amount of the resident funds.",2017-02-01
9176,KINDRED NURSING AND REHABILITATION-MARYVILLE,445245,1012 JAMESTOWN WAY,MARYVILLE,TN,37803,2013-10-30,356,C,0,1,TB8Y11,"Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on October 28, 2013, at 8:50 a.m., of the entry hall bulletin board revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for Friday, October 25, 2013, and had not been updated to reflect current nursing staff in the facility on October 28, 2013. Interview with the Administrator at the time of the observation on October 28, 2013, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility had failed to post accurate staffing.",2017-02-01
9339,TENNOVA HEALTH CARE-TENNOVA TCU,445360,900 EAST OAK HILL AVENUE,KNOXVILLE,TN,37917,2013-11-14,356,C,0,1,PKP011,"Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis at the beginning of each shift. The findings included: Observation on November 12, 2013, at 8:20 a.m., during the initial tour revealed nurse staffing was posted at the nurse's station and the document was blank. Interview with Licensed Practical Nurse (LPN) #1, on November 12, 2013, at 8:30 a.m., in the nurse's station confirmed the facility failed to complete the nurse staffing data for November 12, 2013.",2017-01-01
9345,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2013-07-31,253,C,0,1,EED511,"Based on observation and interview, the facility failed to maintain a clean comfortable environment. The findings included: Observations of the facility on July 29, July 30, and July 31, 2013, revealed a continuous strong foul odor noticeable throughout the facility. Interview with the Administrator, in the Administrator's office, at 1:30 p.m., on July 31, 2013, confirmed the facility had recurring strong odors, of unknown origin, throughout the facility since December 2012.",2017-01-01
9608,LIFE CARE CENTER OF CLEVELAND,445244,3530 KEITH ST NW,CLEVELAND,TN,37311,2013-07-24,356,C,0,1,N5FK11,"Based on observation and interview, the facility failed to post the current nursing staff report. The findings included: Observation on July 22, 2013, at 5:45 a.m., of the facility's nursing staff information posted on the skilled hall revealed the date of July 19, 2013. Interview with Registered Nurse (RN) #1, on July 22, 2013, at 6:00 a.m., at the skilled hall confirmed the facility nursing staff report was dated July 19, 2013, and had not been updated. Interview with the Assistant Director of Nursing (ADON), on July 23, 2013, at 2:00 p.m., in the south hall revealed the Weekend Supervisor was responsible to update the facility nursing staff report on weekends. Further interview revealed the ADON was responsible to update the facility nursing staff report on weekdays. Further interview confirmed the nursing staff report was dated July 19, 2013, when the ADON updated the information on July 22, 2013.",2016-11-01
9672,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2013-03-27,372,C,0,1,GMRI11,"Based on observation and interview, the facility failed to contain garbage and refuse in a sanitary manner for two of three outside dumpsters. The findings included: Observation on March 25, 2013, at 10:15 a.m., outside the facility, revealed two dumpsters for garbage and one dumpster for cardboard. Two dumpster had holes rusted through the metal exterior and one dumpster did not have a lid. Interview with the Assistant Dietary Manager on March 25, 2013, at 10:15 a.m., confirmed two of the dumpsters had holes and one dumpster did not have a lid.",2016-11-01
9705,LIFE CARE CENTER OF RHEA COUNTY,445494,10055 RHEA COUNTY HIGHWAY,DAYTON,TN,37321,2013-07-31,159,C,0,1,8BPS11,"Based on review of personal trust fund accounts and interview, the facility failed to allow residents access to personal funds for forty-five residents with a personal trust fund account managed by the facility. The findings included: Interview with Resident #92 on July 30, 2013, at 10:04 a.m., in the resident's room revealed, . Can't get it (money from personal trust fund account) on weekends and I hate that . Review of the facility personal trust fund account dated July 30, 2013, revealed the facility manages personal trust fund accounts for forty five residents. Interview with the Receptionist on July 31, 2013, at 1:20 p.m., in the Business Office Manager's office confirmed residents only have access to personal funds Monday through Friday, 7:30 a.m. to 4:30 p.m.",2016-11-01
9740,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2013-05-08,356,C,0,1,ECUM11,"Based on observation and interview the facility failed to post accurate nurse staffing information from April 26 through April 29, 2013. The findings included: Observation on April 29, 2013, at 7:35 a.m., near the main entrance of the facility, revealed the nurse staffing information posted was dated Friday, April 26, 2013. Interview with the acting Director of Nursing (aDON), at the time of the observation, confirmed the staffing information should be updated daily, and the current posting was inaccurate and had not been updated or accurate for three days.",2016-10-01
9760,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2013-05-08,356,C,0,1,CUKB11,"Based on observation and interview the facility failed to ensure the correct nurse staffing was posted. The findings included: Observation on initial tour May 6, 2013, at 5:30 a.m., revealed staffing posted at each nursing unit dated May 3, 2013. Interview with Licensed Practical Nurse (LPN) #8 on May 6, 2013, at 5:30 a.m., at the Unit Three nursing station confirmed the staffing posted was dated May 3, 2013. Interview with LPN #9 on May 6, 2013, at 5:40 a.m. at the Unit One nursing station confirmed the staffing posted was dated May 3, 2013. .",2016-10-01
10004,DOUGLAS NURSING HOME,445434,2084 W MAIN ST,MILAN,TN,38358,2012-08-30,167,C,0,1,X3BF11,"Based on observation and interview, it was determined the facility failed to ensure that the survey results were readily accessible to all residents without requesting to see the results. The findings included: During an interview in the room of the resident council president (Resident #9) on 8/27/12 at 5:30 PM, the council president stated she was unaware of the location of the survey results. Observations on 8/27/12 following the interview at 5:30 PM revealed the survey results were found on top of the fish tank in a labeled book, but not accessible to wheelchair residents. Observations on 8/29/12 at 9:00 AM, revealed a sign posted in the hallway across from the main lobby that documented Survey results posted: End table main lobby, Nurses Station #1, Outside Main Dining Room. Observation at that time revealed the survey results were placed on the top of the fish tank out of reach of a wheelchair bound resident. There was no evidence of the survey results at nurses station #1. There was a plastic holder on the wall across from the Birds Nest Cafe (main dining room) but there was nothing in the holder. On 8/30/12 at 10:00 AM, the surveyor took the administrator to the front lobby to see the posting of the survey results. The administrator stated, The (survey) results are on the fish tank. The administrator was asked if a resident in a wheelchair could reach the survey results located on the fish tank. The administrator placed the book containing the survey results on the coffee table and stated, now they can. The surveyor accompanied the administrator to nurses station #1. The administrator went inside the locked nurses' station and opened a cabinet where the survey results were found. The administrator was asked how the residents would obtain the results to review when they are locked up inside the nurses' station. The administrator stated, They would have to ask a nurse for them. The surveyor pointed out the plastic holder on the wall from the Birds Nest Cafe but it was empty. The administrator stated, They (survey results) should be in there.",2016-09-01
10142,GOLDEN LIVINGCENTER - SPRINGFIELD,445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2012-06-27,167,C,0,1,K59011,"Based on observation and interview, it was determined the facility failed to ensure that survey results were readily accessible for all residents and visitors to view without having to ask. The findings included: Observations on 6/27/12 at 9:50 AM, revealed the state survey results were located in the front lobby on a side wall in a wooden holder with a small sign approximately 3 inches long and 1/2 inch wide with State Survey Results attached to it. There was a chair placed in front of it. There were no other posted signs throughout the facility that indicated where the state survey results were located. During an interview in Resident #121's room on 6/26/12 at 7:50 AM, Resident #121 (the Resident Council President) was asked if the state inspection results were available to read without having to ask. Resident #121 stated, .don't know where they (state survey results) are, don't know about that (state survey results) . During an interview in the front lobby area on 6/27/12 at 10:00 AM, Resident #189 was asked if he knew where the state survey results were located. Resident #189 stated, No. During an interview in the front lobby area on 6/27/12 at 10:05 AM, the Administrator was asked if there was a sign posted indicating the location of the state survey results in the facility. The Administrator stated, There used to be one right here on this wall, it's not there now (pointing to the wall at the receptionist desk), I will get another one posted.",2016-07-01
10183,POPLAR POINT HEALTH & REHABILITATION,445150,131 N TUCKER,MEMPHIS,TN,38104,2011-12-15,514,C,0,1,ZLNH11,"Based on observation and interview, it was determined that 21 of 21 sampled residents resident records were not readily accessible and systematically organized by the facility causing a delay in obtaining necessary information which resulted in an additional day of survey. The findings included: Observations of medical records revealed that some of the medical records were documented in the computer system, and some were on hard copy with no organization of how the information was to be obtained. Records were not complete on the computer, resulting in multiple requests for hard copies which were also not complete or not obtained by facility staff when requested. During an interview in the conference room on 12/12/11 at 10:30, the Director of Nursing revealed that the facility had installed a new computer system resulting in medical records on 2 separate systems.",2016-07-01
10195,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2013-03-12,356,C,0,1,0KZP11,"Based on observation and interview, the facility failed to post nurse staffing data in a prominent place readily accessible to residents and visitors on a daily basis. The findings included: Observation on March 10, 2013, at 8:45 a.m., in the front hall off the lobby, revealed the posted nurse staffing data was dated March 8, 2013. Interview with Licensed Practical Nurse #1 on March 10, 2013, at 8:50 a.m., in the front hall off the lobby, confirmed the posted nurse staffing data was dated March 8, 2013, and was not current.",2016-07-01
10235,WHITEHAVEN COMMUNITY LIVING,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2012-08-29,156,C,0,1,RWBL11,"Based on observation and interview, it was determined the facility failed to prominently display the nursing home information posting that contained how to apply for Medicare / Medicaid benefits, contact advocacy groups and the state agency, and how to file a grievance on 4 of 4 (8/26/12, 8/27/12, 8/28/12, and 8/29/12) days of the survey. The findings included: Observations in the front lobby on 8/26/12, 8/27/12, 8/28/12, and 8/29/12 revealed no information was posted related to an application for Medicare and Medicaid, names and telephone numbers of advocacy groups or the state agency, and no complaint or grievance statement information displayed for public and resident access. During an interview in the business office on 8/28/12 at 9:45 AM, the facility Administrator was asked if the required postings were posted for public viewing. The Administrator stated, .I don't know what happened to them, they were here . There is stuff up here we don't need and then there is stuff we need that is not .",2016-07-01
10252,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2012-02-29,156,C,0,1,6K9O11,"Based on review of facility documentation and interview, it was determined the facility failed to notify the residents of their right to request a demand bill to appeal the denial for termination of Medicare services for 28 of 32 residents reviewed. The findings include: Review of the facility's Noncoverage of Medicare Denial letters identified that 32 residents were given notices that their Medicare coverage was to be terminated. Twenty-eight of the 32 residents had not reached the maximum benefit days allowed by Medicare (non-technical denial) and were terminated for not meeting the requirements for skilled services. Although, notification letters were sent within the required 48 hour time frame the letter failed to include the opportunity for residents to request a demand bill to appeal the denial. During an interview in the conference room on 2/29/12 at 4:30 PM, the Admission Director was asked if residents were given the choice to submit a demand bill. The Admission Director stated, .we were using the wrong form. No, the residents were not given notification of their right to request a demand bill to appeal the denial.",2016-07-01
10263,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2012-02-29,514,C,0,1,6K9O11,"Based on observation and interview, it was determined that 35 of 35 sampled resident records were not readily accessible and systematically organized by the facility which resulted in a delay in obtaining necessary information to complete the survey process. The findings included: Observations of medical records revealed that some of the medical records were documented in the computer system, and some were on hard copy with no organization of how the information was to be obtained. Records were not complete on the computer, resulting in multiple requests for hard copies which were also not complete or not obtained by facility staff when requested. During an interview in the conference room on 2/27/12 at 11:00 AM, the Director of Nursing revealed that the facility had upgraded the previous computer program and information had not been transferred in the upgrade resulting in medical records on 2 separate systems. During an interview at the B Hall nurses station on 2/29/12 at 10:30 AM, Nurse #3 stated, .I can't ever find anything that I need when I look in this computer .",2016-07-01
10273,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2013-02-27,356,C,0,1,VOPK11,"Based on observation and interview, the facility failed to post nurse staffing information on a daily basis. The findings included: Observation on February 25, 2013, at 9:50 a.m., revealed the nurse staffing information posted was dated February 22, 2013. Observation and interview on February 25, 2013, at 9:55 a.m., with the Director of Nursing, on the first floor hallway, revealed the posted nurse staffing information was dated February 22, 2013. Interview with Director of Nursing, at the time of the observation, confirmed the nurse staffing information had not been posted daily since February 22, 2013.",2016-07-01
10333,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2012-12-19,172,C,0,1,R1IS11,"Based on observation and interview, the facility failed to ensure the residents had knowledge of the Ombudsman's role in the facility and how to contact the Ombudsman's office. The findings included: Observation on December 18, 2012, at 8:30 a.m., revealed the Long Term Care Ombudsman's contact number posted in the hallway adjacent to the business office. Interview with the Resident Council President on December 18, 2012, at 8:45 a.m., in the resident's room, revealed the resident had no knowledge of the Ombudsman's name; and had no knowledge of the role of an Ombudsman to assist residents residing in long term care. Interview on December 18, 2012, with the Activity Director in the activities office at 9:10 a.m., confirmed the Activities Department assisted the residents with resident council meetings. Continued interview revealed the Activity Director did not know who the Ombudsman was, and had not seen a representative from the Ombudsman's office stating, .can't remember how long, but it's been a long time . Continued interview confirmed the facility failed to ensure the residents had knowledge of the Ombudsman.",2016-07-01
10394,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2013-05-21,356,C,0,1,TX3711,"Based on observation and interview, the facility failed to post the daily nurse staffing data as required. The findings included: Observation and interview on May 19, 2013, at 9:45 a.m,, in the front lobby, with the Administrator and Assistant Director of Nursing, confirmed the daily nurse staffing data had not been posted as required.",2016-07-01
10410,PICKETT CARE AND REHABILITATION CENTER,445390,129 HILLCREST DRIVE,BYRDSTOWN,TN,38549,2013-02-25,205,C,0,1,OQ8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide notice of bed hold policy for one resident (#59) and family member (#F1) of four family interviews conducted. The findings included: Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident Transfer form dated September 16, 2012, revealed the resident was sent to the hospital for elevated temperature, and an increaced cough with production of yellow/green sputum. Medical record review revealed no documentation the family was informed of the bed hold policy. Interview with family member(#F1), on February 20, 2013 at 4:48 p.m., in the resident's room, revealed the family had not been notified of the facility policy permitting return to the facility and the bed hold policy. Interview with the Social Worker on February 22, 2013, at 1:28 p.m., in the social work office, confirmed no written notice was given to the residents for bed hold when discharged to the hospital. Further interview with the Social Worker on February 25, 2013, at 1:50 p.m., in the social work office,confirmed the nurses are responsible for notifying the families, but there was not a written policy on this.",2016-07-01
10413,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2012-12-12,159,C,0,1,D5E211,"Based on interview and review of resident personal funds accounts, the facility failed to make funds available to residents on weekends for forty-four of forty-four residents with personal funds accounts. The findings included: Interview with resident #96 on December 10, 2012, at 2:46 p.m., in the J/K hall Dayroom, revealed the residents did not have access to money from their personal funds on the weekends. Further interview revealed the facility had staff available to distribute funds during business hours on weekdays and residents had to receive money by 4:00 - 5:00 p.m., on Fridays for the weekend. Review of the facility's list of residents with personal funds accounts revealed the facility managed accounts for forty-four residents. Interview with the manager of the personal funds accounts on December 12, 2012, at 2:00 p.m., in the Front Office, confirmed the facility had two people available to dispense funds Monday through Friday between 7:00 a.m., and 5:00 p.m. Further interview confirmed the residents did not have access to money from their personal funds accounts on the weekends.",2016-07-01
10490,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2013-03-27,356,C,0,1,L5ID11,"Based on observation and interview, the facility failed to post daily nurse staffing information. The findings included: During initial tour of the facility on March 25, 2013, at 10:00 a.m., in the front entrance lobby, the posted staffing of personnel was observed on the first floor. The .Daily Staffing Report . was dated March 23, 2013, and included no posted staffing for day or evening shift personnel. The posted staffing included only those numbers for the eleven p.m. to seven a.m. shift. The .Daily Staffing Report . also did not have a number filled-in for .Total Resident Census . Interview with the Administrator on March 25, 2013, at 10:00 a.m., in the front entrance lobby, confirmed the posted staffing was not for the current day and confirmed the resident census information was not included on the posting.",2016-07-01
10491,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2013-03-27,372,C,0,1,L5ID11,"Based on observation and interview, the facility failed to ensure the proper containment of waste. The findings included: Observation and interview with Dietary Staff (DS) #1 on March 27, 2013 at 2:17 p.m., of the outside garbage and waste fat revealed two 55-gallon drums for waste fat storage located behind the building beside the garbage dumpsters. Continued observation and interview revealed one of the drums was covered with a lid and one did not contain a lid or any covering. Continued observation revealed the uncovered drum was 3/4 full of waste fat and had food container debris floating on top of the waste fat. Interview with the DS #1 verified one drum of waste fat was uncovered and stated, the drums are picked up by (the contracted vender) as needed .and should be covered. Interview with the Food Service Director on March 27, 2013, outside the Food Service Department, at 3:15 p.m., verified the facility failed to ensure the stored waste fat was not properly contained.",2016-07-01
10495,BAPTIST HEALTH CARE CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2013-04-17,371,C,0,1,MO0C11,"Based on observation and interview the facility failed to maintain proper sanitation of equipment in the dietary department. The findings included: Observation on April 16, 2013, at 8:24 a.m., in the dietary department with the dietary manager, revealed a fire sprinkler sprayer above the cooking range with a build-up of grease and dust on it. Interview with the dietary manager, at that time, confirmed the fire sprinkler sprayer, above the cooking range, had a buildup of grease and dust on it and needed cleaning.",2016-07-01
10525,"NHC HEALTHCARE, SEQUATCHIE",445126,"360 DELL TRAIL, PO BOX 878",DUNLAP,TN,37327,2012-08-30,356,C,0,1,HX3011,"Based on observation and interview the facility failed to accurately post the nurse staffing ratio. The findings included: Observation on August 27, 2012, at 10:20 a.m., in the front entrance area, revealed nurse staffing information was posted near the business office entrance, and the date on the report was for August 24, 2012. The staffing report indicated for day shift (7a.m. - 3 p.m.) one RN (Registered Nurse) and five LPNs (Licensed Practical Nurse) working with total hours for RN was eight and the total hours for LPN was eight. Interview with the Director of Nursing on August 27, 2012, at 11:30 a.m., in the Director of Nursing office, confirmed the posted staffing was incorrect and was not current.",2016-06-01
10566,HARDIN CO NURSING HOME,445372,935 WAYNE ROAD,SAVANNAH,TN,38372,2012-08-22,167,C,0,1,CT3611,"Based on observation and interview, it was determined the facility failed to ensure the survey results were readily accessible to the residents on all 3 days of the survey (8/20, 8/21 and 8/23/12). The findings included: Observations on all 3 days of the survey (8/20, 8/21 and 8/23/12), revealed the survey results in a notebook in the entrance hallway to the nursing home. This was behind two double doors separating the nursing home from the front entrance and not easily accessible to residents. During the resident council representative interview in Resident #57's room on 8/22/12 at 3:15 PM, Resident #57 was asked if the state inspection results are available to read without having to ask. Resident #57 stated, .I am not sure about this, really don't know, have not seen them. During an interview in the board room on 8/22/12 at 2:55 PM, the Administrator was asked about the survey results and where they were posted. The Administrator stated, They are posted in the main entrance. The Administrator confirmed the survey results are not easily accessible to the residents.",2016-06-01
10577,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2012-12-13,364,C,0,1,FR3Z11,"Based on medical record review, interview and observation, the facility failed to serve palliative vegetables for seven (#12, #73, #76, #88, #122, #141, and #171) residents of twenty residents interviewed. The findings included: Medical record review of the most recent Minimum Data Set Assessment for residents #12, #73, #76, #88, #122, #141, and #171 revealed all were oriented to year, month, date and were determined to be interviewable by the facility according to the Brief Interview for Mental Status (BIMS). Interviews conducted on December 10 and 11, 2012 with residents #12, #73, #76, #88, #122, #141, and #171 revealed each resident was asked scripted questions including, Does the food taste good and look appetizing? Each of the resident answered, No to the question. Observation and interview with the Administrator and the Director of Nursing (DON), on December 12, 2012, at 12:00 p.m., in the main dining room, included a sampling of the food served for the noon meal to the residents. The Administrator and the DON sampled the oriental vegetables , green beans, and macaroni and cheese. Interview with the Director of Nursing and the Administrator following sampling the food revealed the vegetables were, Tastless and Mushy in texture. Further interview revealed the macaroni and cheese was Starchy in texture with moderate taste. Interview with the Administrator and DON in the dining room on December 12, 2012, at 12:08 p.m., confirmed the facility failed to serve palliative vegetables to the residents.",2016-06-01
10578,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2012-12-13,371,C,0,1,FR3Z11,"Based on observation, review of Material Safety Data Sheets and interview, the facility failed to store food in a sanitary manner. The findings included: Observations of the kitchen food preparation area, on December 10, 2012 at 8:55 a.m., revealed an open bucket containing Oasis 146 cleaning solution, stored next to food under the food preparation table. Review of the Material Safety Data Sheet (MSDS) revealed Oasis 146 is a fluid sanitizer solution and is an eye irritant. Interview with the Dietary Manager (DM), in the kitchen, on December 10, 2012, at 9:00 a.m , confirmed the open bucket contained Oasis 146 and was setting next to a 5 gallon container of cooking oil, one gallon container of teriyaki sauce, other assorted cooking sauces, and multiple boxes of open gloves. The dietary manager further stated I know it's not supposed to be there, but we always keep it there. Further interview with the dietary manager on December 10, 2012, at 9:15 a.m., in the dietary department, confirmed cleaning solutions were not to be stored next to food.",2016-06-01
10580,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2013-02-12,172,C,0,1,DN0M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide notification of access to representatives of the state and the ombudsman to three (#57, #107, and #27) of three residents interviewed. The findings included: Medical record review of a quarterly Minumum Data Set (MDS) dated [DATE], for resident #57 revealed the resident scored a 15 on the brief interview for mental status (BIMS), indicating the resident was cognitively intact. Interview with resident #57 on February 4, 2013, at 4:06 p.m., in the resident's room, revealed the resident was not informed on how to contact representatives of the state or the ombudsman. Medical record review of a quarterly Minumum Data Set (MDS) dated [DATE], for resident #107 revealed the resident scored a 11 on the brief interview for mental status (BIMS), indicating the resident was cognitively intact. Interview with resident #107 on February 6, 2013, at 7:43 a.m., in the resident's room, revealed the resident was not informed on how to contact representatives of the state or the ombudsman. Medical record review of a quarterly Minumum Data Set (MDS) dated [DATE], for resident #27 revealed the resident scored a 15 on the brief interview for mental status (BIMS), indicating the resident was cognitively intact. Interview with resident #27 on February 6, 2013, at 10:30 a.m., in the resident's room, revealed the resident was not informed on how to contact representatives of the state or the ombudsman Interview with the Activity Director and the Activity Assistant on February 6, 2013, at 2:44 p.m., in the dining room, revealed the resident's access to representatives of the state or the ombudsman had not been discussed with any of the residents, nor had it been discussed during any resident council meetings.",2016-06-01
10791,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2012-09-26,167,C,0,1,L8M811,"Based on observation and interview, the facility failed to ensure state survey results were readily accessible for all residents. The findings included: Observation on September 25, 2012, at 11:00 a.m., in the hallway near the nurse's station, revealed the state survey results were in a notebook located in a plastic container attached to the wall approximately five feet from ground level. Further observation revealed the results were not accessible to any residents who were confined to a wheelchair without asking for assistance from staff. Interview with the Director of Nursing on September 25, 2012, at 11:00 a.m., near the survey results, confirmed the survey results were posted too high for residents who were in a wheelchair and were not readily accessible.",2016-05-01
10881,SPRING MEADOWS HEALTH CARE CENTER,445402,220 STATE ROUTE 76,CLARKSVILLE,TN,37043,2011-07-15,167,C,0,1,LULX11,"Based on observation and interview, it was determined the facility failed to post a notice indicating the availability of the survey results and failed to ensure the survey results were readily accessible for all residents in the facility. The facility had a census of 98 residents. The findings included: Observations of the facility on 7/13/11 at 2:20 PM, revealed there was no notice posted indicating the location and availability of the survey results. The survey results notebook was located in a plastic wall container, in a corner by the business office window, approximately 5 feet from the floor with no notice to indicate the survey results were in the plastic wall container. The survey results were not readily accessible to wheelchair bound residents. During the group interview, in the activity room on the new wing, on 7/12/11 at 9:30 AM, the nine residents identified as alert and oriented by the facility (Residents #1, 10, 14 and 15 and Random Residents #4, 7, 8, 9 and 10) stated they did not know where the survey results were posted and had not seen them. During an interview in the Administrator's office, on 7/14/11 at 10:55 PM, the Administrator stated, he moved (survey results) by the business office because they kept stealing them off the bulletin board. Moved them (survey results) out of the parlor 3 or 4 years ago.",2016-04-01
10906,SODDY-DAISY HEALTH CARE CENTER,445408,701 SEQUOYAH ROAD,SODDY-DAISY,TN,37379,2012-11-30,241,C,0,1,UZYR11,"Based on observations and interviews the facility failed to maintain the diginity of twenty-two residents of thirty-eight residents observed in two dining rooms. The findings included: Observation of the main dining room, on November 26, 2012 at 12:05 p.m., revealed staff applying cloth bibs/clothing protectors to twenty residents without asking the residents before applying the bib. Interview with Certified Nursing Assistant (CNA) #1, on November 26, 2012, at 12:05 p.m. confirmed the residents were not asked prior to applying the bibs. Observations of the restorative dining room, on November 26, 2012, at 11:57 a.m., revealed two residents were not asked before having cloth bibs/clothing protectors applied by staff. Interview with the Administrator, in the conference room, on November 28, 2012 at 11:10 a.m., revealed the facility did not have a written policy regarding the use of clothing protectors, but the facility practice was for staff to ask the resident if they wanted a clothing protector prior to applying the protector.",2016-04-01
10918,SENATOR BEN ATCHLEY STATE VETERANS' HOME,445484,ONE VETERANS WAY,KNOXVILLE,TN,37931,2012-11-16,241,C,0,1,C96E11,"Based on observation, interview, and review of facility policy, the facility failed to provide an environment that maintains or enhances each resident's dignity of thirty-two of seventy-five observed resident's during the dining observation. The findings included: Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed two Certified Nursing Assistants (CNAs) placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 13, 2012, at 12:10 p.m., in the Assisted Dining Room, revealed the Assistant Director of Nursing (ADON) and two CNAs placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 14, 2012, at 5:15 a.m., in the Restorative Dining Room, and 5:45 a.m., in the Assisted Dining Room, revealed CNAs placed large cloth napkins on the resident's chest without asking the resident prior to placement. Interview with the ADON on November 13, 2012, at 12:20 p.m., in the Assisted Dining Room, confirmed the staff placed large cloth napkins on each resident as a clothing protector without asking the residents if they wanted them. Interview with the Restorative Manager on November 14, 2012, at 6:00 a.m., in the Restorative Dining Room, confirmed the napkins were placed as clothing protectors without asking the residents if they wanted them. Review of facility policy, Dignity and Quality of Life Policy, revealed .using bibs or other clothing protectors instead of napkins except by Resident's choice . Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study on one resident at a table of three. Prior to and during, observation the SLP failed to acknowledge the other residents at the table. Observation on November 13, 2012, at 12:25 p.m., in the Assisted Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study on one resident at a table of four. Prior to and during, the observation the SLP failed to acknowledge the other residents at the table. Interview with the Restorative Manager, on November 13, 2012, at 12:45 p.m., in the Assisted Dining Room, confirmed the SLP did not interact with the other resident's while performing the swollowing assessment in the presence of other resident's.",2016-04-01
10959,QUALITY CARE HEALTH CENTER,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2012-11-07,159,C,0,1,1H8G11,"Based on resident and facility staff interviews and review of the Trust Fund Trial Balance accounts, the facility failed to provide weekend access to personal funds managed by the facility for eligible residents. The findings included: Interview with resident #72 on November 5, 2012, at 3:10 p.m., and resident #152 on November 6, 2012, at 10:00 a.m. confirmed the residents were not able to access personal funds at the facility on the weekends. Review of the facility's Trust Fund Trial Balance revealed ninety-four residents with personal fund accounts managed by the facility. Interview with the Administrative Assistant, in the business office on November 7, 2012, at 8:50 a.m., confirmed the facility does not routinely provide access to personal funds for the residents on weekends.",2016-03-01
11091,BRIDGE AT MONTEAGLE (THE),445393,26 SECOND STREET,MONTEAGLE,TN,37356,2012-10-10,356,C,0,1,WZJG11,"Based on observation, review of facility documentation, and interview the facility failed to post the correct nurse staffing data. The findings included: Observation of the Nurse staffing on October 8, 2012, at 10:30 a.m., revealed seven Licensed Practical Nurses (LPN) and one Registered Nurse (RN) on duty. Observation and Review of the POS [REDACTED]. The actual staffing was seven LPN's and one RN. Interview with the DON confirmed the posted Nurse staffing was not accurate.",2016-03-01
11208,DONELSON PLACE CARE & REHABILITATION CENTER,445148,2733 MCCAMPBELL AVENUE,NASHVILLE,TN,37214,2014-02-05,356,C,0,1,G0VM11,"Based on observation and interview, the facility failed to post the current facility staff hours. The findings included: Observation on February 3, 2014, at 10:20 a.m., in the hall in the administrative office area, revealed the Daily Staffing form was dated January 30, 2014. Interview on February 3, 2014, at 10:25 a.m., in the hall in the administrative office area, with the Staffing Coordinator, confirmed the staffing report posted was not current.",2016-02-01
11509,BELCOURT TERRACE NURSING HOME,445273,1710 BELCOURT AVENUE,NASHVILLE,TN,37212,2012-10-11,170,C,0,1,6IO711,"Based on interview, it was determined the facility failed to ensure mail was delivered on Saturday's for the 41 residents residing in the facility. The findings included: During an interview in Resident #8's (resident council president) room on 10/9/12 at 2:30 PM, the resident council president was asked if the residents received mail on Saturday. The resident council president wrote on her communication board, Monday through Friday . During an interview in the hall outside the Social Service's office on 10/11/12 at 1:10 PM, the Administrator was asked if mail was delivered on Saturday. The Administrator stated, .The post office (mail delivery worker) brings the mail in and puts it in the cabinet in the entryway (on Saturday). The business office manager, when she comes in on Monday, separates the mail for delivery to the residents . Right now I guess we are in violation of resident rights .",2016-01-01
11621,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2012-03-28,371,C,0,1,KLTU11,"Based on observation, review of facility documentation, and interview, the facility failed to document and maintain records for the monitoring of dish washing and rinsing machine temperatures. The findings included: Observation on March 27, 2012, at 8 a.m., in the kitchen, with the dietary manager, revealed the Dish Room Temperature and Product Record logs were incomplete. Further observation of a log with no date or month,(dietary manager stated this was the month of December, 2011) revealed no documentation of temperature checks on the following dates: 9th, 21st, 27th, 29th, 30th . Further review of the logs revealed no documentation of temperature checks for the breakfast cycle on the following dates: 7th, 13th, 15th, 16th, 27th, 29th, 30th and 31st. Continued review revealed no documentation of temperature controls for the lunch and supper cycles on the following dates: 13th, 25th, 26th, 27th, and 29th. Review of the facility policy, Dish Machine Temperature Log, revealed .the food service director will provide the dishwashing staff with a log to be posted near the dish machine .the food service director will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process .staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal .the food service director will spot check the log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures . Interview with the Dietary Manager and Food Service Director, at 8:15 a.m., on March 27, 2012, in the kitchen, confirmed the facility logs were incomplete and failed to follow the policy and procedure related to dish machine temperatures.",2015-12-01
12343,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2013-05-30,372,C,0,1,4XKZ11,"Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. The findings included: Observation and interview with the Dietary Manager on May 28, 2013, at 10:58 a.m., revealed three outside dumpsters with trash exposed. Continued interview with the dietary manager confirmed the dumpster lids are to be kept closed.",2015-09-01
12380,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,167,C,0,1,60TM11,"Based on observation, and interview, the facility failed to make available the survey results in one of the two facility buildings. The findings included: Observation on July 13, 2011, at 10:50 a.m., with a Registered Nurse (RN #3) for the East 200 hall, revealed a sign posted in the main lobby of the Dalton Building which stated the latest survey results could be located in the main lobby of the Hamilton building and the main lobby of the Dalton building. Continued observation revealed the survey results were not located in the main lobby of the Dalton building. Interview with the Registered Nurse (RN #3) on July 13, 2011, at 10:50 a.m., in the main lobby of the Dalton building, confirmed the survey results were not available in the main lobby the Dalton building as directed by the sign.",2015-08-01
12572,MAURY REGIONAL HOSPITAL SNU,445398,1224 TROTWOOD AVE,COLUMBIA,TN,38401,2012-04-25,156,C,0,1,YU7V11,"Based on interview, it was determined the facility failed to provide residents with liablity and/or appeal notice(s) for three Medicare beneficiaries who were discharged from the facility in the past 6 months. The findings included: During an interview in the Activity/Dining room on 4/25/12 at 3:30 PM, the surveyor asked the Administrator to provide the liability and appeal notice(s) given for 3 discharged Medicare covered residents who had days of Medicare covered services left. The Administrator stated, ""...We don't do them (Liability Notices and Beneficiary Appeal Rights). At admission it is understood we are a short term facility..."" During an interview in the Social Worker's office on 4/25/12 at 5:00 PM, the Social Worker was asked if she gave Medicare covered residents the required liability and/or appeal notice(s) to a resident with Medicare Skilled coverage remaining. The Social Worker stated, ""...No...""",2015-08-01
12740,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,372,C,0,1,P03R11,"Based on observation, review of facility policies and procedures, and interview, the facility failed to dispose of garbage and refuse properly. The finding included: Observation of the dumpster refuse area with the Executive Chef on May 31, 2011, at 9:45 a.m., revealed the following: 1. A side door was fully opened on one (dumpster #1) of four dumpsters. 2. A side door was half-way opened on one (dumpster #2) of four dumpsters. 3. Liquid refuse leaking from dumpster #1, ran onto and accumulated on top of the concrete slab where the four dumpsters were positioned. The dumpster refuse and surrounding area produced a strong, foul, and soured odor. 4. Trash and refuse on the ground surrounding two of four dumpsters, included: disposable latex gloves, empty condiment containers, an empty facial tissue box, scattered pieces of paper, and a milk container. Review of a facility policy and procedure titled ""Garbage and Trash Disposal"" revealed, ""...Poor garbage and trash storage and disposal can lead to other types of problems. Various types of vermin will be attracted to the unit because of poor refuse storage on the outer premises. The vermin can enter and then cause further problems once inside...3. Using dumpsters for refuse disposal. The lids to these should be kept closed and waste should be in tight-closing, sealed, plastic bags. It will reduce odors and keep the dumpster clean..."" Interview with the Executive Chef on May 31, 2011, at 9:50 a.m., at the dumpster refuse area, confirmed the facility failed to ensure the proper disposal of garbage and refuse. .",2015-07-01
12885,PERRY COUNTY NURSING HOME,445503,127 E BROOKLYN AVENUE,LINDEN,TN,37096,2011-02-09,170,C,0,1,FQSN11,"Based on interview, it was determined the facility failed to ensure residents' mail was promptly delivered to 1 of 1 (Resident #16) sampled residents and 9 of 9 Random Residents (RR) #1, 2, 3, 4, 5, 6, 7, 8 and 9) participating in the group interview. This could affect every resident in the facility that receives mail. The findings included: During the group interview in the dining room on 2/7/11 at 2:30 PM, Resident #16 and RRs #1, 2, 3, 4, 5, 6, 7, 8 and 9 complained that mail was not delivered on the weekends. During an interview in the Social Services office on 2/8/11 at 11:00 AM, the Social Worker (SW) was asked if the residents receive mail on weekends. The SW stated, ""...They (the residents) do not get their mail on weekends. There is no one in the front office. It (the mail) would be handed out on Monday."" During an interview in the Director of Nursing's office on 2/9/11 at 9:04 AM, the Administrator was asked if the residents receive mail on the weekends. The Administrator stated, ""... there is no one here to hand it (mail) out on the weekends...""",2015-07-01
13060,GRACELAND NURSING CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2013-02-04,356,C,0,1,WDSU11,"Based on observation and interview, it was determined the facility failed to prominently post nurse staffing information on a daily basis on 6 of 6 (1/28/13, 1/29/13, 1/30/13, 1/31/13, 2/1/13 and 2/4/13) days of the survey. The findings included: Observations in the facility on 1/28/13 through (-) 2/1/13 and 2/4/13 revealed nurse staffing information was not prominently posted. During an interview in the staffing coordinator's office on 2/4/13 at 2:10 PM, the Staffing Coordinator was asked if the staffing is posted everyday. The Staffing Coordinator stated, ""Yes ma'am, we have a daily and a monthly schedule posted. The staffing coordinator was then asked if the staffing was posted on the 400 hall everyday. The staffing coordinator stated, ""Yes ma'am..."" The nursing staffing information was not prominently posted in an area readily accessible to residents and visitors.",2015-05-01
13241,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2011-05-18,371,C,0,1,6XTQ11,"Based on observation and interview, the facility failed to ensure male staff wore protective coverings on beards, and to ensure hazardous sanitizing solution was separated from food products. The findings included: Observation on May 16, 2011, at 6:20 p.m., in the kitchen, revealed Dietary Aide #1 had a full unprotected beard. Interview with Dietary Aide #1 at the time of observation revealed the aide had just completed serving food on the supper tray line. Continued observation with Dietary Aide #1 revealed two small buckets without lids, filled with multiquat (sanitizing solution) were stored next to the cooking oil. Interview with the Dietary Aide #1 at time of observation confirmed the sanitizing solution was stored next to the cooking oil. Observation of the lunch tray line on May 17, 2011, at 11:23 a.m., in the kitchen, with the Dietary Supervisor, revealed Dietary Aide #2 working the food serving tray line with an unprotected beard. Observation also revealed Dietary Aide #1 working in the area around the food with an unprotected beard. Interview with the Dietary Supervisor on May 17, 2011, at 11:25 a.m., in the Dietary Department, confirmed the male staff had no protection on the beards, verified staff are to wear protection on the beards, and food products are not to be stored with hazardous sanitizing solutions. .",2015-03-01
13268,LIFE CARE CENTER OF EAST RIDGE,445296,1500 FINCHER AVENUE,EAST RIDGE,TN,37412,2011-03-08,356,C,0,1,97TY11,"Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis, at the beginning of each shift. The findings included: Observation on March 6, 2011, at 9:30 a.m., revealed nurse staffing data was posted in the front lobby of the facility. Continued observation revealed the posted nurse staffing data was dated March 4, 2011. Interview on March 6, 2011, at 10:15 a.m., in the front lobby of the facility, with Licensed Practical Nurse (LPN) #3, confirmed the facility failed to post the nurse staffing data on a daily basis, and had not been updated since March 4, 2011.",2015-03-01
13334,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2011-05-04,371,C,0,1,BD0E11,"Based on observation, facility policy review, and interview, the facility failed to maintain the appropriate temperature for milk on the tray line for the residents. The findings included: Observation in the dining room, on May 2, 2011, at 11:35 a.m., with the Assistant Dietary Manager, revealed a closed thermal cooler with ice located at the end of the steam table tray line. Continued observation revealed the cooler was filled with half-pint (236 milliliter) cartons of milk. Further observation revealed the temperature of the sampled carton of milk was 46 degrees Fahrenheit (F). Review of the facility's policy, Safe Food Temperatures, revealed ""...All cold items need to be held at 40 (degrees) F or lower. To keep food cold during service surround product with draining ice or keep refrigerated and only pull a few out as needed during service..."" Interview on May 2, 2011, at 11:50 a.m., with the Assistant Dietary Manager, in the dining room, confirmed the milk was not maintained at a safe temperature range.",2015-02-01
13373,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2011-05-12,356,C,0,1,QZPF11,"Based on observation and interview the facility failed to post the nurse staffing data. The findings included: Observation on May 9, 2011, at 10:00 a.m., revealed there was no nurse staffing data posted in a prominent place readily accessible to residents and visitors. Observation and interview on May 9, 2011, at 10:30 a.m., with the Director of Nursing, outside the Administrator's office, confirmed the nurse staffing data was not posted.",2015-02-01
13374,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2011-05-12,167,C,0,1,QZPF11,"Based on observation and interview the facility failed to post a notice indicating the availability of the most recent State survey results in a place readily accessible to residents. The findings included: Observation on May 9, 2010, at 10:00 a.m., revealed the results of the most recent State survey were located outside the Administrator's office in a white binder, inside a plastic holder, approximately five feet off the floor, with no signage to indicate the survey results were located inside the white binder. Group interview on May 10, 2011, at 9:00 a.m., with residents (#14, #15, #16, #17, and #18), in the beauty shop, revealed the residents were not aware of where the results of the most recent State survey were located. Interview with resident #11 on May 11, 2011, at 4:45 p.m., in the courtyard, revealed the resident had no knowledge of the location of the posting of the facility's survey results. Observation and interview on May 10, 2011, at 2:40 p.m., with the Administrator, revealed the results of the most recent State survey were located outside the Administrator's office in a white binder, inside a plastic holder, approximately five feet off the floor. Continued observation and interview confirmed there was no signage to indicate the survey results were located inside the white binder, and confirmed the survey results were not accessible to residents requiring a wheelchair for locomotion.",2015-02-01
13690,HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2010-06-03,161,C,0,1,QG9811,"Based on review of the facility's surety bond, review of the facility's trust fund bank statements and interview, it was determined the facility failed to purchase a surety bond of an adequate amount to assure the security of personal funds for 3 of 3 (February, March and April 2010) months reviewed. The facility had 102 of 116 residents with money deposited in the trust fund account. The findings included: 1. Review of the facility's surety bond revealed an insured amount of $80,000.00. 2. Review of the facility's trust fund bank statement for February, 2010 documented the following balances more than the surety bond amount: a. 2/3/10 - $91,589.21. b. 2/4/10 - $91,498.21. c. 2/5/10 - $91,308.21. d. 2/8/10 - $90,308.21. e. 2/9/10 - $89,950.52. 3. Review of the facility's trust fund bank statement for March, 2010 documented the following balances more than the surety bond amount: a. 3/3/10 - $91,162.97. b. 3/4/10 - $91,062.97. c. 3/5/10 - $90,776.35. 4. Review of the facility's trust fund bank statement for April, 2010 documented the following balances more than the surety bond amount: a. 4/5/10 - $91,582.41. b. 4/6/10 - $91,048.21. During an interview in the front office on 6/3/10 at 9:20 AM, the Administrator verified the surety bond was not of an adequate amount to cover the balances as noted above.",2014-11-01
14235,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2010-04-07,254,C,,,CHDZ11,"Based on observation and interview the facility failed to provide clean wash cloths for all residents. The findings included: Interview during the resident council meeting in the activity room on April 5, 2010, at 1:45 p.m., revealed a shortage of wash cloths. Interview on April 6, 2010, at 2:35 p.m., on 100 hall, with certified nurse assistant #2 and #5 revealed a frequent shortage of wash cloths. Observation on April 6, 2010, at 2:30 p.m. and 3:50 p.m.; April 7, 2010, at 7:45 a.m. and 9:15 a.m., revealed the following: No wash cloths in the ""clean linen room"", and fewer than 6 wash cloths on the 500 and the 100 hall linen carts. Interview with the administrator on April 7, 2010, at 11:30 a.m., in the conference room confirmed the frequent shortage of wash cloths.",2014-03-01
14329,CRESTVIEW HEALTH AND REHABILITATION,445409,2030 25TH AVE N,NASHVILLE,TN,37208,2012-05-15,170,C,,,LH9611,"Based on policy review and interview, it was determined the facility failed to ensure that residents' mail was sent and promptly received for 1 of 10 Random Resident (RR #5) and sampled residents interviewed. This potential affects all residents mailing or receiving mail on weekends, since the facility has the post office to hold the mail until Monday due to no one is in the front office on weekends. The findings included: Review of the facility's ""Resident Mail delivery and Distribution"" policy documented, ""...All resident mail is delivered unopened and postmarked (for outgoing mail) within 24 hours."" During an interview in RR #5's room on 5/10/12 at 9:00 AM, RR #5 was asked about receiving mail in the facility. RR #5 stated, ""Don't know if it (mail) is delivered on Saturdays."" During an interview in the Assistant Director of Nursing's office on 5/11/12 at 8:45 AM, the Activities Director stated, ""Mail is delivered Monday through Friday to front office, placed in our box and we deliver it to the residents. No mail delivery on weekends because there is no one in the front office. We are not able to get into front office on weekends. No mail delivery on Saturday, they (post office) wait till (until) Monday, Post office holds the mail till Monday because there is no one in the front office. Wished we could get it on weekends, have been incidents where residents have asked (on weekends) if they had any mail.""",2014-01-01
1,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2019-05-31,609,D,1,1,4KQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #53) sampled residents reviewed for abuse. The findings include: The facility's Patient Protection .for Allegations/Incidents of Abuse . policy revised 12/11/17 documented, .The patient has the right to be free from abuse .5. Identification Policy .Any patient event that is reported to any partner by patient .will be considered an allegation of .abuse .if it meets any of the following criteria .patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others .6. Reporting Policy .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, which indicated the resident was cognitively intact for decision making, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment in both of her lower extremities. Review of the facility investigation of Resident #53's allegation of abuse revealed no documentation the abuse allegation was reported to the State. Interview with the Administrator on 5/29/19 at 5:09 PM in the Conference Room, the Administrator was asked when he was made aware of the allegation of abuse by Resident #53. The Administrator confirmed he was made aware of the allegation on 5/16/19, the day the allegation was made. The Administrator was asked if the allegation was reported to the State and the Administrator stated, .No. Interview with Resident #53 on 5/30/19 at 7:55 AM, in Resident #53's room, Resident #53 was asked if she had ever been abused or mistreated in the facility. Resident #53 stated, Well, uh .an aide .she just was rough . Resident #53 confirmed she reported the incident. Resident #53 stated she reported, That I thought she was physically and verbally abusing me. Resident #53 was asked if she was satisfied with the way the investigation was handled by the facility. Resident #53 stated, Yeah, I didn't want to make a big deal about it . Resident #53 confirmed that she felt safe in the facility.",2020-09-01
3,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2019-05-31,689,D,0,1,4KQP11,"Based on observation and interview, the facility failed to ensure the environment was free from accident hazards when 1 of 2 (Sling Lift) resident transfer lifts was not functioning properly. The findings include: Observations in Resident #36's room on 5/31/19 at 10:35 AM revealed Certified Nursing Assistant (CNA) #1 and #2 used a sling lift to transfer Resident #36 from his bed to his wheelchair. The lift malfunctioned momentarily and left Resident #36 suspended over his bed in the sling. The lift began working again, and the CNAs were able to lower Resident #36 into his wheelchair. Interview with CNA #2 outside Resident #36's room on 5/30/19 at 10:42 AM, CNA #2 was asked if there had been problems with the sling lift. CNA #2 stated, Here lately, yes. We have told maintenance. CNA #2 was asked how long the lift had been malfunctioning. CNA #2 stated, I'm not sure, maybe a week. Interview with CNA #3 on the West Hall on 5/30/19 at 10:43 AM, CNA #3 was asked if she had any problems with the sling lift. CNA #3 stated, Once in awhile it will get stuck .It's been reported to maintenance. We were just talking about it Monday. CNA #3 was asked what she was told by the maintenance staff. CNA #3 stated, He said he would look at it and try to oil it up or something. Interview with CNA #4 at the nurses station on 5/30/19 at 10:46 AM, CNA #4 was asked if she had any problems with the sling lift. CNA #4 stated, A little bit. CNA #4 was asked how long that had been going on. CNA #4 stated, It's been recent .I've noticed it usually happens more on bigger patients that it struggles with . Interview with the Director of Maintenance on 5/30/19 at 12:22 PM in the Conference Room, the Director of Maintenance was asked if he worked on the patient lifts. The Director of Maintenance stated, Not much .I just check the batteries. The Director of Maintenance was asked if he had been notified of a problem with the sling lift. The Director of Maintenance confirmed he had been notified. The Director of Maintenance was asked when he was first made aware of the problem. The Director of Maintenance stated, It's sporadic. Two or 3 months ago, we swapped the batteries. Interview with the Director of Maintenance on 5/30/19 at 1:17 PM in the Conference Room, the Director of Maintenance stated, .A service call was put in last Thursday, and then (Central Supply CNA) made a follow-up call yesterday because he hadn't come out yet. Interview with CNA #6 on 5/30/19 at 2:31 PM in the Conference Room, CNA #6 was asked if she ever had problems using the sling lift. CNA #6 stated, It's horrible. Something is wrong with the cord that connects the remote to the lift .You have to move the cord thingie around or it won't work. Sometimes it will and sometimes it won't. It has been reported . Interview with the Director of Nursing (DON) on 5/30/19 at 2:53 PM in the Conference Room , the DON was asked if the sling lift had been serviced recently. The DON stated, They are coming Tuesday. The DON was asked why the lift needed to be serviced. The DON stated, (Central Supply CNA) called them about something about it. Interview with the Administrator on 5/30/19 at 5:23 PM in the Conference Room, the Administrator was asked if he was aware the staff were having problems with the sling lift. The Administrator stated, I've heard a lot of discussion about the lift today. The Administrator was asked how often the lift was serviced. The Administrator stated, .Annually . The Administrator was asked if he was concerned the staff continued to use the sling lift even though it had not been working properly. The Administrator stated, No . Interview with the Central Supply CNA on 5/31/19 at 8:10 AM in the Conference Room, the Central Supply CNA was asked about the problem with the sling lift. The Central Supply CNA stated, The tilt wasn't working. The maintenance man looked at it. It was Tuesday (5/28/19) when I put the call (lift service call) in. They were closed on Monday (5/27/19) . The Central Supply CNA was asked if the sling lift was still being used for resident transfers. The Central Supply CNA confirmed it was still in use. The Central Supply CNA was asked how long she had known they were having problems with it. The Central Supply CNA stated, Last week one of the techs (CNAs) came to me .",2020-09-01
4,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2017-08-16,371,D,0,1,RSCD11,"Based on observation and interview the facility failed to ensure food was properly stored in 1 of 1 (Nurses Station) nourishment refrigerators. The findings included: Observations in the medication room nourishment refrigerator on 8/15/17 at 3:20 PM, revealed 3 cans of strawberry yogurt with expiration date of 8/4/17 and 3 cans of Glucerna Therapeutic Nutrition Classic Butter Pecan with expiration date of 5/1/17. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/17 at 3:20 PM, in the medication room, LPN #1 was asked should expired food be kept in the refrigerator. LPN #1 stated, No it should not. Interview with LPN #2 on 8/16/17 at 1:04 PM, at the nurses' station, LPN #2 was asked what is the process for ensuring expired foods are removed from the refrigerator in the medication room. LPN #2 stated, It is dietary's responsibility for checking and removing expired food from the refrigerator .we stand at the door and allow them to go in and check everything and if something is expired then they remove it and replace it. Interview with the Dietary Manager (DM) on 8/16/17 at 1:08 PM, in the dining room, the DM was asked what the process is for removing expired food from the refrigerator in the medication room. The DM stated, Every night they go and rotate the oldest to the front and new to the back and check the dates and that is suppose to be done nightly. The DM was asked should you expect to find expired food in the refrigerator. The Dietary Manager stated, No. Interview with the Director of Nursing (DON) on 8/16/17 at 1:11 PM, at the nurses' station, the DON was asked what is the process for ensuring the nourishment refrigerator in the medication room is free of expired food. The DON stated, Dietary comes out and checks the refrigerator .we open the door and stand there while they check it but I expect my nurses to check for expiration dates prior to administering medications or food to a resident.",2020-09-01
5,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2018-08-22,641,D,0,1,X6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for hospice and cognition for 2 of 12 (Resident #32 and 41) sampled residents reviewed. 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The significant change Minimal Data Set ((MDS) dated [DATE] failed to document that hospice services had been provided during the assessment period. Interview with the MDS Coordinator on 8/22/18 at 2:26 PM, in the MDS office, the MDS Coordinator was asked if the MDS dated [DATE] should have been marked to reflect the resident was receiving hospice services. The MDS coordinator stated, Yes. 2. Medical record review revealed Resident # 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not have a Brief Interview for Mental Status (BIMS) which is a score that indicates the resident's cognitive function. The MDS was not completed (blank) in the cognitive assessment area. Interview with the MDS Coordinator on 8/21/18 at 2:23 PM, in the MDS office, the MDS Coordinator was asked if the BIMS score and cognitive function section of the MDS was completed. The MDS Coordinator stated, No.",2020-09-01
7,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2019-08-01,686,D,0,1,4FC811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide timely assessments and treatments for pressure ulcers for 1 of 4 (Resident #87) sampled residents reviewed for pressure ulcers. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/4/19 documented, .has alteration in skin r/t (related to) dark and reddened areas to (R) (right) foot . The Admission assessment dated [DATE] documented, .bilat (bilateral) red heels and outer rt (right) heel dark purple area (possible SDTI) (suspected deep tissue injury) . Review of the wound assessments revealed no assessments were completed for Resident #87's sDTI from admission until 7/9/19. Review of the Treatment Administration Records dated (MONTH) and (MONTH) 2019 revealed there was no documentation of wound care treatment for [REDACTED]. Medical record review revealed the pressure ulcer to the right heel remained an unstageable pressure ulcer and had not worsened. Observations in Resident #87's room on 7/18/18 at 2:05 PM, revealed Resident #87, she had a unstageable pressure injury to the right lateral heel. Interview with the Director of Nursing (DON) on 7/31/19 at 2:38 PM, in the Education Room, the DON was asked if Resident #87 was admitted with any pressure ulcers. The DON stated, .she had a suspected deep tissue injury .outer right heel . The DON was asked if weekly skin assessments and treatments should have been done. The DON stated, Yes. The DON was asked when the wound assessments and treatments began. The DON stated, .we started (MONTH) 2nd . The facility was unable to provide documentation that wound assessments and treatments were provided for Resident #87's pressure ulcer that was identified on 6/4/19, until 7/2/19.",2020-09-01
8,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2019-01-16,842,D,0,1,6O2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure Physician order [REDACTED].#340 and #341) of 3 residents reviewed of 29 residents sampled. The findings include: Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form, undated, revealed the physician had not signed and dated the resident's POLST form. Medical record review revealed Resident #341 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 1/4/19 revealed the POLST form was not signed by the resident and the health care professional preparer of the form. Interview with the Director of Nursing (DON) on 1/16/19 at 8:47 AM, in the DON's office, confirmed the POLST forms were to be completed within 24 hours of admission to the facility. Continued interview confirmed the facility failed to ensure the POLST forms were complete for Resident #340 and #341.",2020-09-01
10,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2020-02-20,679,D,0,1,UNET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of activity calendars, observations, and interviews, the facility failed to provide activities for 4 of 25 sampled residents (Resident #131, Resident #132, Resident #230, and Resident #232) who resided on the Sub-Acute Unit. Failure to provide residents with an activity program has the potential to affect the residents' physical, mental, and psychosocial well-being. Findings Include: Review of the St. Barnabas/Siskin West Policy Activities Department updated/revised 12/2018 indicated the definition of an activity was any activity other than activities of daily living that enhanced the resident's well-being. The policy indicated the activities would be person-centered and highlight the resident's quality of life. The procedure indicated the AD would visit the resident after admission to obtain likes and dislikes. The procedure further indicated the AD would educate the resident on happenings on the unit and she would provide an activity calendar for the resident. The policy stated, .should the patient/resident decline to attend activities .they will be provided with in-room options or 1:1 (one on one) opportunities .puzzles, books, magazines, movies and music. Resident #131 was admitted to the facility on [DATE] for occupational and physical therapy following a motor vehicle accident. Review of the Baseline Care Plan dated 2/17/2020, revealed it did not address Resident #131's activity preferences. Review of Resident #131's Resident Activities Assessment Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important for the resident to do her favorite activities; and it was somewhat important for the resident to have books, newspapers, and magazines to read, to listen to music she liked, to do things with groups of people, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/23/2020 revealed Resident #131 was cognitively intact. Observations of Resident #131 conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #131 had not been approached to attend activities and had not been observed in activities, either at her bedside, or in a group setting. Review of the Activity Calendar posted on the hallway by the nurses station on the 2nd floor Subacute Unit on Wednesday 2/19/20 at 8:49 AM, indicated good morning rounds were to be done at 9:00 AM; tai ji (Tai Chi) at 10:30 AM; at 2:00 PM Oliver visits; bingo was at 2:15 PM; and chili tasting was at 2:45 PM. During interview with Resident #131 on 2/19/2020 at 3:49 PM, at her bedside, Resident #131 was asked if she participated in the activities provided by the facility. The resident stated No, I didn't realize they had activities. Resident #131 was asked if anyone had come around and asked if she wanted to attend the activities, or to bring her a magazine or newspaper, and the resident stated, No. The resident was asked, if she were asked to participate in activities would she, and the resident stated, It would depend on the activities. The resident was asked if she would have attended this afternoon's bingo and chili tasting, and Resident #131 stated, I would have liked that. Resident #132 was admitted to the facility on [DATE] for occupational and physical therapy following a right total knee arthroplasty. Review of Resident #132's Baseline Care Plan dated 2/13/2020, showed it did not address the resident's activity preferences. Review of the admission MDS with an ARD of 2/19/2020 revealed Resident #132 was cognitively intact. Review of the Resident Activities Assessment, Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important to Resident #132 to listen to music he liked; and somewhat important to have books, newspapers, and magazines to read, keep up with the news, to do things with groups of people, to do his favorite activities, and to go outside to get fresh air when the weather was good. Observations conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #132 had not been approached to attend activities and had not been observed in activities, either at his bedside, or in a group setting. During interview with Resident #132 on 2/19/2020 at 2:04 PM, the resident was asked if he had participated in any of the activities since he had been in the facility. Resident #132 stated, No. Resident #132 was asked if he was aware there were activities offered at the facility, and the resident stated, No, no one has told me anything about any activities. Resident #132 was questioned if the staff were to ask, would he participate in activities, and the resident stated, I probably would. Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Social History/Admission assessment dated [DATE], revealed Resident #230 had a mini mental score of 15, which indicated Resident #230 had intact cognition. Record review of Resident #230's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/17/2020, indicated it was very important to the resident to have animals around, keep up with the news, and participate in religious services. Observation on 2/18/2020 at 9:39 AM, revealed Resident #230 was in his room. There was an activity calendar posted in the resident's room. Interview with Resident #230 on 2/18/2020 at 9:39 AM, revealed no one had informed him of any activities going on that day. Resident #230 stated Lord I did not even know that the activity calendar was posted in the room. He stated he had not read the calendar and did not think anyone had ever come to him to discuss activities. Resident #230 stated he would be interested in going to activities according to the time of day. He stated he liked working in the yard. Observation on 2/18/2020 at 2:18 PM, revealed Resident #230 was sitting up in a chair in his room. There was not an activity person in his room or on the unit, even though pet therapy was listed on the activity calendar in his room and on the big activity calendar in the hallway by the nurse's station. Interview with Resident #230 on 2/18/2020 at 2:18 PM, in his room, revealed someone had been in earlier and asked if he wanted a magazine, and that was all. Observation of Resident #230 on 2/19/2020 at 9:00 AM, revealed he was sitting up in a chair in his room and was getting ready to go to therapy at 9:45 AM. Resident #230 stated no one had been by and invited him to any activities that day, but he had a calendar that might tell what was going on. Observation on 2/19/2020 at 3:32 PM, in the dining/activity room on the 2nd floor Subacute Unit, revealed no chili tasting activity was taking place, which was listed as an activity on the calendar for 2:45 PM. Observation on 2/19/2020 at 3:35 PM, in the dining/activity room on the 3rd floor, showed a chili tasting event was occurring. Resident #230 was not in attendance. Review of the Activity Calendar posted on the hallway by the nurse's station on the 2nd floor Subacute Unit indicated on Thursday (MONTH) 20, 2020 showed there would be seven activities that day. The calendar indicated that at 8:30 AM the news would be done; 9:00 AM would be good morning rounds; 10:00 AM would be coffee activity; 11:00 AM papers were to be delivered; 11:30 AM would be bible story time; and at 2:30 PM Wheel of Fortune would be played. Interview with Registered Nurse (RN) #6 on 2/20/2020 at 12:23 PM, revealed she had not discussed any activities with Resident #230. During interview with Resident #230 on 2/20/2020 at 12:35 PM, he was in his room and his wife was at the bedside. Resident #230 stated he did not go to the chili tasting yesterday and no one had been by for morning coffee that morning. Resident #230 state he needed to get out more and socialize. Resident #230 further stated he liked chili. Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #232's Social History/Admission assessment dated [DATE], revealed the resident had a mini mental score of 15, which indicated intact cognition. Record review of Resident #232's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/13/2020 revealed it was very important to the resident to keep up with the news and to go to religious services. Observation and interview on 2/18/2020 at 1:04 PM, revealed Resident #232 was sitting in his room watching television. During interview, Resident #232 stated he was not aware of any activities that the facility provided. Resident #232 stated he did not think anyone had ever discussed activities with him. He stated he might go to an activity, but it depended on what time it was. He stated he liked music. Resident #232 stated he had not gone to the sing a long that was posted on the calendar for the past Saturday, and he had not been invited to go. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 11:30 AM, in the dining/activity room on the 2nd floor Subacute Unit, revealed some residents would say they were bored and they had cabin fever. LPN #5 stated she would tell the residents they were welcome to come out in the hallway and visit. LPN #5 stated she would tell the resident about the books and puzzles available on the unit and there were puzzles and activities upstairs on the 3rd floor. LPN #5 stated she would give the residents the activity calendar and told them how to get to it on the 3rd floor. Interview with the Director of Nursing (DON) on 2/20/2020 at 2:24 PM, in her office, revealed very rarely did a subacute person go to activities because they were mainly interested in getting well and going home. The DON stated the subacute stays were only two weeks and then they go home. The DON stated there was an activity calendar in each room and a big calendar in the hallway that the subacute residents passed by when going to therapy. The DON stated she was not sure if the subacute had to have documentation activities were done. The DON stated the residents in the subacute unit wanted to just go home and she felt it did not pose any risk to the residents if they did not go to activities. Interview with the AD on 2/20/2020 at 10:30 AM, in her office on the 3rd floor, revealed she had been the Activity Director for 4 years. The AD stated she used to have 3 Activity Assistants, but now it was only her. She used to have more volunteers and now she has fewer. The AD stated the nurses did the initial activity assessment, she would check over the assessment, then she would go talk to the residents and gave the residents an activity calendar, and she would go over it with the resident. She offered the residents cards, magazines, puzzles, Sudoku, and CD players. She told the residents where the books and puzzles could be located. The AD stated most of the rehab residents were more self-directed and could do their own interests. Most of the rehab residents wanted to do their rehabilitation, go home, and were not much interested in activities. The AD stated the facility has 50's singing once a month and church services on Sundays and Tuesdays. If the resident filled out that religious services or music was important to them, then she tried to get them to the services. The AD stated she did not work on the weekends and could not say if Resident #230 or Resident #232 had attended any religious services on the weekends. She did not keep track of who attended the weekend activities. Pet therapy had been cancelled because of the weather. Resident #230 and Resident #232 had not participated in the chili tasting activity yesterday and had not attended any facility activity. The AD had tried to come down to the 2nd floor yesterday to do an activity, but had only been there a few minutes and the 3rd floor paged her, and she had to go back up there to do their activity. She stated the residents on the 3rd floor liked to get her attention and looked to her for activities. The AD stated she tried to get to the 2nd floor to at least pass out books and magazines. During interview with the Administrator on 2/20/2020 at 1:30 PM, in the conference room, the Administrator was asked what her expectations were related to activities for the Sub-Acute Unit residents. The Administrator stated I expect the sub-acute residents to be asked if they want to participate in activities whenever there are activities going on, or if they want to do a bedside activity. The Administrator added the Activity Director told her she hasn't had the chance to get to the subacute residents this week.",2020-09-01
11,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2020-01-02,580,D,1,0,14S411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to notify the physician in a timely manner of a malfunction of a Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube inserted through the abdominal wall and into the stomach for nutrition, fluids, and medications) for 1 resident (#2) of 3 residents reviewed for PEG tubes. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 5/9/19 revealed Resident #2 was care-planned for Infection Potential related to Feeding Tube, and Nutritional Status, Dependent on Tube Feed with interventions including (caloric, fiber fortified nutritional tube feeding) at 60 milliliters an hour for 18 hours, assess for changes in condition and notify medical staff, and MD (medical doctor) to replace PE[NAME] Medical record review of the Resident Progress Notes dated 9/1/19 at 1:38 PM, for Resident #2 revealed .in am, previous shift .nurse reported perforation to PEG tube. Noted large hole at end of catheter. Removed without difficulty and replace with new 24F (French) 20 cc (cubic centimeters) tube .restarted without concerns per supervisor .Husband updated, left message with NP (Nurse Practitioner) . Further review revealed no documentation the physician or the NP was made aware of the PEG tube perforation and the removal and reinsertion of a new PEG tube. Medical record review of the Physician's Orders on 9/1/19 revealed no documentation of an order to reinsert the PEG tube. Medical record review of an untitled typed letter, dated 10/14/19, and signed by the Unit Supervisor RN revealed .pt. (patient) had a removable gastric tube in place that had perforated and some of the balloon was visible from tube site entrance .nurse notified house supervisor .replaced with facility gastric tube . Interview with the Compliance Registered Nurse (RN) (former Unit House Supervisor) on 1/2/20 at 12:15 PM, in the Conference Room, confirmed she was the supervisor on duty on 9/1/19 when the Licensed Practical Nurse (LPN) (no longer employed at the facility), notified her of the perforated PEG tube. Continued interview confirmed she and the LPN removed the perforated PEG tube, reinserted a new PEG tube without notifying the physician. Interview with the Compliance RN, the Director of Nursing, and the Corporate Consulting RN on 1/2/20 at 1:50 PM, in the Conference Room, confirmed the facility did not notify the physician or NP of the PEG perforation and removal and reinsertion of the PEG tube.",2020-09-01
12,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2018-03-20,655,D,0,1,48GW11,"**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 care and treatment of [REDACTED].#459) of 49 sampled residents reviewed for baseline care plans. The findings included: Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated 3/9/18 revealed Resident #459 was discharged with an indwelling urinary catheter. Medical record review of a baseline care plan dated 3/9/18 revealed no care plan for the care and treatment of [REDACTED]. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed Resident #459's care plan failed to address the treatment and care of the indwelling urinary catheter.",2020-09-01
13,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2018-03-20,684,D,0,1,48GW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview the facility failed to obtain a physician's order for an indwelling urinary catheter for 1 resident (#459) of 3 residents reviewed for urinary catheters of 49 sampled residents reviewed. The findings included: Review of the facility policy, Electronic Health Record IMAR System, dated 4/24/15 revealed .admission orders [REDACTED]. Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated 3/9/18 revealed .MD (Medical Doctor) order for (urinary catheter) .Catheter this admission: yes . Medical record review of Physician's Orders dated 3/9/18 revealed no order for an indwelling urinary catheter. Observation of Resident #459 on 3/18/18 at 11:00 AM and 2:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Observation of Resident #459 on 3/19/18 at 9:25 AM and 3:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 at 3:30 PM, the 400 hall nursing station, revealed they were unaware Resident #459 had an indwelling urinary catheter and there was no physician's order. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed the admitting nurse failed to properly reconcile admission orders [REDACTED]. Continued interview confirmed .We missed it .",2020-09-01
14,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2018-03-20,689,D,0,1,48GW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide new interventions after a fall for 1 resident (#40) of 6 residents reviewed for falls of 49 residents reviewed. The findings included: Review of the facility's NHC FALLS PROGRAM undated revealed .Purpose: To identify patients at risk for falling and to implement the appropriate interventions .3) Implement appropriate interventions 4) Evaluate the effectiveness of the interventions . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 1 staff to transfer, dress, toilet, complete personal hygiene, and the resident was non-ambulatory and total assistance of 1 staff for bathing. Review of the POS [REDACTED]. The new intervention was to keep the resident in high traffic areas. Review of the POS [REDACTED]. The new intervention was to educate staff to keep the resident in high traffic areas. Observation and interview with Resident #40 on 3/20/18 at 9:15 AM in the dining area revealed he was sitting in his geri chair (in the down position) at the table finishing his breakfast. States he falls because he is clumsy. I'm 96, old people fall Observation of Resident #40 on 3/20/18 at 2:30 PM, in the dining area revealed the resident sitting in the geri chair asleep, with the chair reclined. Interview with the Licensed Practical Nurse (LPN) Risk Manager on 3/20/18 at 2:45 PM, in the conference room revealed after reviewing the 9/21/17 and 10/8/17 Post Falls Investigations confirmed the new intervention for the 9/21/17 fall was to keep the resident in a high traffic area, this would include educating the staff of the new intervention, and would be added to the Certified Nurse Assistant work sheet. Continued interview confirmed Resident #40 received a hematoma to his forehead with the 10/8/17 fall, and the resident was in his room, which is not in a high traffic area. Further interview confirmed the new intervention to educate staff to keep the resident in a high traffic area was not a new intervention.",2020-09-01
16,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2020-02-20,625,D,1,0,D8DU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to provide a bed hold notice for 1 resident (Resident #1) transferred to a psychiatric facility of 3 transferred residents reviewed. The findings included: Review of the facility's policy titled, Bed Hold Policy dated 10/19/2019 showed .Residents and/or responsible parties will be fully informed of options regarding the holding or releasing of a bed when the resident is temporarily transferred from the facility or is on a therapeutic leave.Upon admission to the facility the resident and/or their representative will be notified in writing of (named facility) Bed Hold Policy.In the event that the resident is transferred out of the facility temporarily, or the resident goes out on a therapeutic leave a copy of the Bed Hold Agreement will be given to the resident or their representative.This process will be followed for all transfers, regardless of payer type. A copy of the Bed Hold Agreement will be placed in the residents Business Office File and a copy of the bed hold agreement will be provided to the resident or their representative. Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to a psychiatric facility. Resident #1 was readmitted to the facility on [DATE], but was discharged again to the psychiatric facility on 7/24/2019 and did not return to the facility. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory loss and exhibited physical and verbal behaviors directed towards others. Review of a Physician's Telephone Order dated 6/8/2020 showed .transfer to (named psychiatric facility).psych eval (psychiatric evaluation). Review of a Physician's Telephone Order dated 7/23/2020 showed .send to (named psychiatric facility) for evaluation + (and) tx (treatment). Medical record review showed no documentation a bed hold notice was provided to the resident or the resident's representative prior to the resident being transferred to the psychiatric facility on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:20 PM, the Administrator stated .I looked through the entire chart and could not find it.did not find a progress note.only thing we have is a resident agreement.does not mention bed hold.both times the resident was sent out to a psych facility.behaviors.combative.nothing for either transfer. The Administrator confirmed the facility did not give the resident or the resident representative a bed hold notification prior to the transfer on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:30 PM, the Nurse Manager confirmed a bed hold policy was not given to the family prior to transferring the resident on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 6:00 PM, the Social Worker confirmed a bed hold policy was not given to the resident or the resident's representative prior. During a telephone interview on 2/20/2020 at 6:30 PM, Resident #1's representative stated she was not made aware of the facility's bed hold policy either verbally or in writing.",2020-09-01
17,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-04-26,609,D,1,0,6SJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, observation, and interviews, the facility failed to report an injury of unknown origin for 1 resident (#3) of 5 residents reviewed. The findings included: Review of the facility policy Resident Rights Abuse of Residents dated 11/14/16 revealed .an injury of unknown origin .must be reported to the Executive Director .Resident Incidents must be reported immediately .not later than 24 hours if the events that cause the allegation do not involve abuse .to other officials (including law enforcement, state survey agency, and adult protective services) .in accordance with applicable law and regulations . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had short and long term memory problems and was severely cognitively impaired for daily decision making skills. Further review revealed the resident required extensive to total assist for activities of daily living (ADL) with 1-2 person assist. Review of a facility investigation dated 3/28/18 revealed Certified Nurse Assistant (CNA) #1 noted bruising to Resident #3's left forehead, which was not present earlier in the day. Further review revealed CNA #1 reported the bruising to Licensed Practical Nurse (LPN) #5. Continued review revealed LPN #5 reported the injury to the Director of Nursing (DON). Interview with CNA #1 on 4/25/18 at 11:30 AM, in the 1 South Breakroom, revealed .I was on my way to lunch . (another CNA) was pushing her (Resident #3) out of the dining room .I brushed her (Resident #3's) hair back from her face and that is when I noticed the bruise .it was purple .reported to the nurse .got her (Resident #3) up and dressed that morning and did not see anything then . Interview with LPN #2 on 4/25/18 11:40 AM, in the 1 South Breakroom, revealed .immediately went and assessed her (Resident #3) .she had a hematoma to the top left of her hairline .the bruising was coming down toward her eye .notified the DON .the Nurse Practitioner was in the facility and came and assessed her .notified the family . Observation on 4/25/18 at 12:00 PM revealed Resident #3 was seated in her wheelchair in the dining room. Continued observation revealed the resident had a slight purplish discoloration from her hairline down the left side of her forehead. Interview with the Administrator on 4/26/18 at 1:30 PM, in his office, confirmed the injury of unknown origin was not reported to Adult Protective Services, Law Enforcement, or the Ombudsman and the facility failed to follow facility policy.",2020-09-01
18,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-04-26,656,D,1,0,6SJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interviews, the facility failed to ensure the comprehensive care plan was person centered for bathing for 2 residents (#1 and #2) of 5 residents reviewed. The findings included: Review of the facility policy Bathing dated 3/7/14 revealed .All Residents complete bathing needs will be met twice weekly, or at a schedule based on resident preference . Review of the facility policy Comprehensive Resident Centered Care Plan dated 11/2/16 revealed .The care plan incorporates the resident's strengths and abilities as well as areas requiring support . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan dated 2/5/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist with transfers, bathing, and dressing with 1-2 person assist. Continued review revealed the resident had a functional limitation of 1 upper and 1 lower extremity. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's care plan dated 3/22/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission MDS dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist for transfers, dressing with 2 person assist, and was totally dependent for personal hygiene and bathing with 1-2 person assist. Interview with Certified Nursing Assistant (CNA) #1 on 4/25/18 at 2:45 PM, on 1 South Household hallway, revealed .most residents get 2 showers a week unless they request more . Interview with Licensed Practical Nurse (LPN) #6 on 4/26/18 at 12:15 PM, in the therapy gym office, revealed . care plan should address the resident's preference and frequency of bathing . Interview with the Director of Nursing (DON) on 4/26/18 at 1:15 PM, in the DON's office, confirmed the care plans for Resident #1 and Resident #2 did not adequately reflect their bathing needs and were not person centered.",2020-09-01
19,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2019-05-02,609,D,1,0,ZMPR11,"**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 an allegation of abuse was reported immediately to the facility Administrator and to other officials (including the State Survey Agency and Adult Protective Services) for 1 resident (#1) of 4 residents reviewed for Abuse on 4 nursing units of 4 sampled residents. The findings included: Review of facility policy Resident Rights - Abuse of Residents revised 11/14/16 revealed .Reporting .1. Any witnessed or allegations of abuse .must be reported to the Executive Director, Administrator or Charge Nurse/Nurse Supervisor .a. Resident Incidents must be reported immediately .to other officials (including law enforcement, state survey agency, and adult protective services) in accordance with applicable law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 30 day MDS dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #3's annual MDS dated [DATE] revealed the resident was cognitively intact. Medical record review of a Psychiatric Progress Note for Resident #3 dated 4/10/19 revealed the resident was attention seeking and inappropriate verbally with staff related to sexuality. Review of a facility investigation dated 4/25/19 revealed Resident #3 reported he witnessed Resident #2 place his hand down the front of Resident #1's pants and Resident #3 told Resident #2 to stop. Continued review revealed Resident #2 replied .I was just checking to see if she (Resident #1) was wet to change . Further review revealed Resident #3 changed details of the alleged incident multiple times during the facility investigation and stated he was not able to see if Resident #2 put his hand under her blanket or inside Resident #1's pants. Continued review revealed Licensed Practical Nurse (LPN) #2 reported while she was feeding Resident #3 in his room on 4/22/19 or 4/23/19, Resident #3 reported the incident to her. Further review revealed Resident #3 also reported the incident to LPN #3 on 4/24/19. Interview with LPN #2 on 5/2/19 at 1:00 PM, in the Administrator's office, confirmed Resident #3 reported the alleged incident to her on 4/22/19 or 4/23/19. Further interview revealed she did not report the allegation because .in my mind .I thought it really didn't happen . Telephone interview with LPN #3 on 5/2/19 at 2:35 PM confirmed she did not report the allegation of abuse because she thought it was .old news . Further interview with LPN #3 confirmed she was aware she should have reported the allegation immediately, but failed to do so. In summary, Resident #3 reported an allegation of abuse to facility staff on 4/22/19 or 4/23/19, but the staff did not report the allegation to the Administrator or the State Survey Agency until 4/25/19.",2020-09-01
20,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-07-27,281,D,1,0,4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Lippincott Manual of Nursing Practice, facility staffing files, facility policy, medical record review, and interview, the facility employed one Licensed Practical Nurse (LPN #9) with an expired license who administered insulin to 3 diabetic residents (#5, #16, and #14) of 17 residents reviewed. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, chapter 2, revealed, .Licensure is granted by an agency of state government and permits individuals accountable for the practice of professional nursing to engage in the practice of that profession, while prohibiting all others from doing so legally . Review of the facility staff certification documents on [DATE] revealed LPN #9's license to practice nursing expired on [DATE]. Review of the facility's staffing files revealed LPN was hired on [DATE]. Medical record review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician order [REDACTED].Humalog (fast-acting insulin for diabetics) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's electronic Medication Administration Record [REDACTED]. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 15 times out of 62 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 16 times out of 54 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar per physician order [REDACTED]. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (fast-acting insulin insulin for diabetics) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 10 times out of 27 opportunities. Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 12 times out of 37 opportunities. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] .12 units .give extra 4 units if (blood glucose) (greater than 300)) . Medical record review of Resident #14's eMAR dated [DATE] at 1:00 PM revealed a blood sugar of 274 with documentation LPN #9 administered 10 units of insulin instead of the ordered 12 units. Continued review revealed the 5:30 PM blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the DON's office, confirmed nurses are to follow the physician's orders [REDACTED]. Interview with the Administrator and DON on [DATE] at 6:30 PM, confirmed, LPN #9 did not have a current license to practice nursing since the hire date in (MONTH) (YEAR). Continued interview confirmed since his employment, LPN #9 failed to follow physician's orders [REDACTED].",2020-09-01
30,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-08-20,554,D,0,1,Q9H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of a facility statement, medical record review, observation, and interview, the facility failed to complete an interdisciplinary team (IDT) assessment for self-administration of medications by 1 resident (#131) of 8 residents reviewed during initial pool process, of 52 residents sampled. The findings include: Review of the facility Administering Medication Policy Statement, revised 12/12, revealed .25. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Review of facility policy Self-Administration of Medication dated 10/18/17 revealed .1. A resident will not self-administer his or her medications until a determination has been made by the interdisciplinary team that the resident can safely perform this task .2. The household Clinical Mentor, (nurseUnit Manager) at the request of the resident, will assess the resident to determine the resident's ability to self-administer his or her medications .findings of the assessment will be documented in the resident's clinical record . Review of a facility statement signed by the Administrator and dated 8/15/18, revealed There is no resident who self-administers medications. Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan dated 5/15/18, revealed the resident was at risk for unstable blood pressure related to Hypertension, .Administer B/P (blood pressure) meds (medications) as ordered .at risk for altered tissue perfusion related to anticoagulant (blood thinner) therapy .Administer meds (Aspirin) at same time daily . Medical record review of a current physician's orders [REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #131 required 2 person assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a Brief Interview for Mental Status (BIMS) Score of 3, indicating severe cognitive impairment. Observation and interview with Resident #131 on 8/13/18 at 9:36 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with the resident revealed the resident requested to have the medications after breakfast. Further interview revealed the resident had not participated in a care plan meeting to determine if self-administration of medication was appropriate. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 9:47 AM, on the 2 South hall, confirmed LPN #1 left the medications on the over bed table .because resident likes to take her medication after she eats . Continued interview confirmed the medication was [MEDICATION NAME], SamE, a baby aspirin, and a [MEDICATION NAME]. Observation of the resident on 8/14/18 at 8:29 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with LPN #1 on 8/14/18 at 8:41 AM, on 2 South, revealed the resident had requested to take the medications after breakfast. Continued interview revealed LPN #1 was unaware if self-administration of medication was care planned for the resident, or if there was written documentation of an IDT assessment for the resident to self-administer medications. Interview with the Director of Nursing (DON) on 8/15/18 at 3:50 PM, in the conference room, confirmed no residents in the facility had been assessed for self-administration of medications. Continued interview confirmed medications were not to be left with residents for self-administration.",2020-09-01
31,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-08-20,656,D,0,1,Q9H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan to address the resident's need for assistive devices during meal times for 1 resident (#54) of 52 sampled residents. The findings include: Medical record review revealed Resident #54 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 required 1 person assistance with dressing and personal hygiene, and 2 person assistance with transfers and set up help for eating. Continued review revealed the resident was on a mechanically altered diet, had an identified weight loss, and had no oral or dental issues. Continued review revealed the resident scored 14 on the Brief Interview For Mental Status (BIMS), indicating he was cognitively intact. Medical record review of the quarterly Care Plan, undated, revealed .potential for weight loss .tremors of hands decrease his ability to self feed, dysphagia, swallowing difficulty .Staff to assist .when tremors are increased .Complete set-up and provide assistance with .eating . Continued review revealed at risk for Aspiration/Choking due to Dysphagia/Cough with intervention to .Assist .no straws .plate guard and weighted utensils with all meals . Medical record review of a clinical nurse's note dated 4/4/18 revealed .resident stated at lunch he couldn't feed himself, requested for staff to feed him . Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating a pureed breakfast provided in divided plate with no plate guard, had hand tremors and was noted to have food on clothing. Further observation revealed no weighted utensils in use. Observation of Resident #54 on 8/14/18 at 9:23 AM, in the resident's room, revealed the resident lying in bed, with the pureed breakfast meal provided in a divided plate with no plate guard, and regular eating utensils present. Continued observation revealed the resident had difficulty feeding himself due to the shakiness/tremors of the hands related to the disease process of [MEDICAL CONDITION]. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed his pureed breakfast was served in a regular plate, with regular eating utensils, and a bowl. Continued observation revealed the resident had obvious tremors of the upper extremities bilaterally. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food of pureed consistency on a regular plate with regular eating utensils, and nectar thick liquids. Continued observation revealed no plate guard and weighted utensils had been provided. Observation of Resident #54 on 8/20/18 at 9:15 AM, in the resident's room, revealed the resident had breakfast food pureed consistency in a divided plate and nectar thick liquids. Further observation revealed no plate guard or weighted utensils had been provided. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed had used a plate guard and it made eating easier. Observation of resident revealed resident had a regular plate without a plate guard. Interview on 8/18/18 at 10:15 AM during the resident observation with Licensed Practical Nurse (LPN) #1 confirmed the facility had failed to provide Resident #54 with a divided plate, a plate guard, and weighted utensils to promote self-feeding at meal time.",2020-09-01
36,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-08-20,690,D,0,1,Q9H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to provide catheter care for 1 resident (#89) of 4 residents reviewed with catheters, of 52 sampled residents. The findings include: Review of facility policy Catheter Care-Indwelling Catheter, dated 1/1/17, revealed .PURPOSE: to prevent infection and provide daily hygiene . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 Day Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with 1 staff member for bed mobility and toileting and required total assistance with 2 staff members for transfers and bathing. Further review revealed the resident required a wheelchair for mobility and was assessed as having an indwelling catheter. Medical record review of admission orders [REDACTED].FC(Foley Catheter)(indwelling urinary catheter) .chg (change) monthly .cath (catheter) care . Medical record review of readmission orders [REDACTED]. Medical record review of a Clinical Nurse Note dated 8/11/18 revealed .catheter replaced with #18 (size) catheter with 20cc (cubic centimeter) balloon (balloon to hold catheter in place) . Medical record review of a Physician order [REDACTED].Urinary Catheter Care q (every) shift .Starting 8/18/18 .Insert indwelling catheter .Every One Month Starting 8/18/18 . Interview with Resident #89 on 8/18/18 at 11:45 AM, in the resident's room, revealed .my catheter was changed just the other day .that was the first time they (facility) changed it .the nurse said she had to change the catheter because I had it since (MONTH) .they don't do catheter care everyday .they only do it on Tuesday and Thursday when I have my bath . Interview with LPN Nurse Mentor #5 on 8/18/18 at 3:56 PM, in the nursing station, confirmed when the resident was admitted to the facility the physician order [REDACTED]. Interview with the Director of Nursing on 8/18/18 at 5:00 PM, in the conference room, confirmed the catheter was to be replaced monthly and catheter care was to be reordered when the resident returned to the facility. Continued interview confirmed catheter care was to be completed daily unless ordered otherwise.",2020-09-01
37,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-08-20,692,D,0,1,Q9H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation and interview, the facility failed to ensure interventions were implemented and monitored to prevent further weight loss for 2 residents (#34, #54) of 5 residents reviewed for nutrition, of 52 residents sampled. The findings include: Review of the Facility Weight Assessment and Intervention Policy revised 9/08 revealed 6 .threshold for significant unplanned weight and undesired loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe .Continued review revealed .Individualized care plans shall address .identified causes of weight loss .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 3 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #34 was independent with eating with assistance of set up only, and had no weight loss. Medical record review of the weight record from (MONTH) (YEAR) through (MONTH) (YEAR) revealed: 5/6/18 126.2 pounds 6/3/18 126 pounds 7/3/18 121.8 pounds 8/5/18 weight 111.2 pounds 8/12/18 weight 115.4 pounds Review of Nutrition Progress assessment dated [DATE] revealed Resident #34's current weight was 126 pounds, Nutrition [DIAGNOSES REDACTED].Intervention: Liberalization of diet, Evaluation .monitor weights and intake . Review of a clinical notes report dated 8/10/18 at 1:45 PM entered by Dietitian #2 revealed a significant weight loss of 8.7 percent, 10.6 pounds from 7/3/18 through 8/5/18. Medical record review of physician's orders [REDACTED].RD (Registered Dietician) recommendation -Weekly wts (weights) x (for) 4 weeks r/t (related to) 8.7% wt loss x 1 month, Refer to Psychiatry (Psych) d/t (due to) wt loss . Review of Physicians Order Sheet and Progress Notes dated 8/15/18 revealed .recommendation per RD: 1) Boost Plus (nutritional supplement drink) TID (3 times per day) between meals . Review of Resident #34's care plan dated 8/16/18 revealed .therapeutic diet as ordered CCD (consistent carbohydrate diet) regular diet. Therapeutic restriction of choice .provide ques and encouragement. Feed (Resident #34) remaining food items .monitor food intake at each meal .Boost three times a day between meals . Interview with LPN #5 in nurse's office in secure unit on 8/18/18 at 3:10 PM revealed the nutritional supplement Boost was documented as given on the Medication Administration Record [REDACTED]. Review on 8/18/18 at 3:10 PM of the Psychiatry referral book in the Nurses office revealed Resident #34 was referred to Psychiatry on 8/10/18. Continued review revealed no documentation the referral had been addressed by Psychiatry. Interview with the DON on 8/18/18 at 4:55 in the conference room confirmed Resident #34 had not been seen by Psychiatry since the referral date of 8/10/18, . should have been since Psych is in the building 2 times a week . Interview on 8/20/18 at 10:19 AM with Dietary Manager and Registered Dietician #1 in the conference room confirmed the facility failed to ensure interventions were implemented to prevent further weight loss. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with hygiene, 2 person assistance with transfers, and dressing, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, weighed 219 pounds, and had no oral or dental issues. Continued review revealed a BIMS Score of 14 indicating the resident was cognitively intact. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with dressing and hygiene, 2 person assistance with transfers, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, had a weight loss of 20 pounds from the previous MDS assessment, with a current weight of 199 pounds, and had no oral or dental issues. Medical record review of the quarterly care plan print date of 6/14/18 revealed .potential for weight loss .tremors of hands decrease his ability to self feed, dysphagia, swallowing difficulty .Staff to assist .when tremors are increased .Complete set-up and provide assistance with .eating . Continued review revealed at risk for Aspiration/Choking due to Dysphagia/Cough with intervention to .Assist .no straws .plate guard and weighted utensils with all meals . Further review revealed the facility failed to develop and implement an individualized care plan to address the identified weight loss of 20 ponds. Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating breakfast provided in a divided plate with no plate guard, had hand tremors and was noted to have food on clothing. Further observation revealed no weighted utensils in use. Observation of Resident #54 on 8/14/18 at 9:23 AM, in the resident's room, revealed breakfast was provided in a divided plate with no plate guard, and regular silverware. Continued observation revealed the resident had difficulty feeding self due to tremors of hands. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed breakfast was served on a regular plate, with regular silverware and bowl. Interview with RD #1 on 8/15/18 at 2:50 PM, in the conference room, revealed RD #1 was unfamiliar with this resident and was not aware of the resident's weight loss or any interventions. Further interview revealed the RD was not able to determine the interventions that were previously initiated on the care plan and if the interventions of weighted utensils and plate guard were discontinued. Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS Coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Continued interview revealed no straws, and the plate guard were active on the care plan for Resident #54. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food pureed consistency, a regular plate and regular silverware. Continued observation revealed no plate guard or weighted utensils. Interview with LPN #1 on 8/18/18 at 10:15 AM, on the 2 South Hall way revealed the resident had a plate guard but it was discontinued. Continued interview revealed the resident used a divided plate with meals. Further interview, in the resident's room, confirmed resident did not have a plate guard, a divided plate or weighted utensils. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hall, revealed the interventions were to be placed on the care plan and updated by the .care plan manager . Continued interview revealed LPN #1was unaware of Resident #54's 20 pound weight loss or any weight loss interventions except a divided plate that had been used. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed Resident #54 had used a plate guard when provided and it made eating easier. Continued observation revealed the resident had a regular plate without a plate guard.",2020-09-01
39,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-08-20,698,D,0,1,Q9H011,"**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 assess and monitor a Central Venous Catheter (CVC) for 1 resident (#133) of 3 residents receiving [MEDICAL TREATMENT], of 52 sampled residents. The findings include: Review of the facility [MEDICAL TREATMENT] protocol, revised 5/2018 revealed .The [MEDICAL TREATMENT] organization will work with the Clinical Mentors in regards to proper care and treatment of [REDACTED]. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident received [MEDICAL TREATMENT]. Continued review revealed the resident scored 5 on the Brief Interview For Mental Status, indicating severe cognitive impairment. Review of a Physicians Orders dated 7/24/18 revealed the resident receives [MEDICAL TREATMENT] 3 times per week. Medical record review of a care plan undated, revealed .Has [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and is at risk for complications .Interventions .Monitor shunt site for any s/s (signs and symptoms) of infection, occlusion, etc . Medical record review of a [MEDICAL TREATMENT] Treatment Sheet print date 8/6/18 revealed current [MEDICAL TREATMENT] access of CVC catheter right chest. Medical record review of the Treatment Administration Record (TAR) dated 7/25/18-8/14/18, revealed no documentation the facility assessed the resident's catheter or dressing after [MEDICAL TREATMENT] treatment. Observation and interview with Resident #133 on 8/15/18 throughout the day revealed the resident had a CVC to the right upper chest for [MEDICAL TREATMENT] vascular access. Continued interview with the resident on 8/15/18 confirmed she was new to [MEDICAL TREATMENT] and didn't not know much about it. Interview with the Director of Nursing on 8/15/18 at 4:55 PM, in the conference room, confirmed there was no documentation the [MEDICAL TREATMENT] CVC had been monitored. Further interview confirmed it should be documented on the TAR.",2020-09-01
47,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2019-08-28,695,D,0,1,CV0B11,"**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 properly store and discard an outdated nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) administration equipment (nebulizer tubing and mask) for 1 resident (#28) of 7 residents reviewed for nebulizer therapy. The findings include: Review of facility policy Administering Medication through Small Volume (Handheld) Nebulizer, revised 1/1/2017, revealed .Store equipment in plastic bag with the resident's name and date on it .Change equipment and tubing every 7 days . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum data set ((MDS) dated [DATE] revealed Resident #28 had a Brief Mental Status Interview (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed Resident #28 required limited assistance with bed mobility, transfers, personal hygiene, and dressing. Medical record review of the Physician's Recapitulation Orders dated 8/2019, revealed a nebulization solution was ordered as needed every 6 hours. Medical record review of the Medication Administration Record [REDACTED]. Observation of Resident #28 on 8/26/19 at 9:55 AM and 3:02 PM, and on 8/27/19 at 8:40 AM, in the resident's room, revealed the nebulizer at the bedside with the mask dated 3/28/19 and not stored in a plastic bag. Observation and interview with Licensed Practical Nurse (LPN) #1 on 8/26/19 at 3:35 PM, in the resident's room, confirmed the date on the nebulizer mask was 3/28/19 and the mask was not stored in a plastic bag. Further interview confirmed the nebulizer equipment had not been changed for 21 weeks. Interview with Director of Nursing (DON) on 8/26/19 at 3:47 PM, in the DON's office, confirmed the facility failed to follow their policy to properly store and discard outdated nebulizer equipment for Resident #28.",2020-09-01
48,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2019-08-28,842,D,0,1,CV0B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure Physician Orders for Scope of Treatment (POST) were completed for 3 residents (#87, #273, and #279) of 31 residents reviewed for advanced directives. The findings include: Review of the facility policy Health Care Decision Making-Advanced Directives - TN (Tennessee), revised 12/7/16, revealed The purpose of this policy and procedure is to ensure residents are informed of their rights to execute an Advanced Health Care Directive .It also provides guidelines for completion of a TN Physician Orders for Scope of Treatment (POST) form, and to facilitate the implementation of the resident's wishes so that they are carried out according to the terms of these documents and applicable law and regulation .Upon admission or as soon as possible thereafter, if the resident does not have Advance Health Care Directives, the Nurse, Nurse Practitioner, or MD (physician) will explain these documents to the resident or representative and provide forms for their review (Appointment of Health Care Agent form; POST form) .Residents wishing to create an Advance Care Plan may do so through completion of the POST form .A POST must contain: 1. Resident's name and signature .4. Physician's signature .Prior to signature, the Physician must discuss the POST form and contents with resident or the responsible party. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's POST form, undated, revealed documentation the resident was Do Not Attempt Resuscitation (DNR) status with Limited Additional Interventions. Continued review revealed Resident #87 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #273's POST form, revealed the resident requested a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed the Physician had not signed or dated the form. Medical record review revealed Resident #279 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #279's POST form, undated, revealed documentation the resident was a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed Resident #279 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Interview with the Director of Nursing on 8/28/19 at 1:28 PM, in the conference room, confirmed the facility .get (advanced directives) upon admission . and were to be signed by the physician and resident or resident representative. Continued interview confirmed the facility failed to ensure facility policy for Advance Directives was followed for Resident #87, #273, and #279.",2020-09-01
49,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2017-05-24,242,D,0,1,2T0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor individual choices for daily schedules for 2 residents (#84, #211) of 21 residents interviewed. The findings included: Medical record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #84 had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. Review of the medication record completed on 5/23/2017 at 3:48 PM revealed Resident #84 had a blood pressure medication ordered with parameters to hold the medication based on the resident's current blood pressure. The medication is set for an 8:00 AM administration schedule. Resident #84 also had an order for [REDACTED]. Observation and interview with Resident #84 on 5/22/2017 at 1:26 PM, in the resident's room confirmed she had not been given the opportunity to choose the time she preferred to be awakened in the morning nor the type of bathing she received. They wake me up at 5 (AM) but I don't get breakfast till 9 (AM). I would like to get up at 7 (AM) .I go (to the shower) on Tuesday and Friday. I didn't choose those days. An interview was completed with Activity Assistant (AA) #1 on 5/23/2017 at 2:10 PM. AA #1 stated, On admission, we fill out an assessment .We don't ask about what time they want to get up in the morning. On 5/23/2017 at 2:55 PM, an interview was completed with Certified Nursing Assistant #1 (CNA). CNA #1 stated she was familiar with Resident #84. I come in at 6:30 (AM). She is usually sleeping then. I go in to get her vitals (blood pressure, temperature, pulse) about 7 (AM). They get done every day. I ask if she wants to get up and she usually gets started with her day at that time. Breakfast comes out about 7:45 AM. Sometimes she says she doesn't want to get up at 7. Observation on 5/24/2017 at 7:05 AM, revealed staff checking vital signs. Observation on 5/24/2017 at 7:50 AM, revealed the breakfast tray was delivered to Resident #84. On 5/24/2017 at 8:05 AM an interview was completed with LPN #1. LPN #1 stated the activities staff ask residents about bedtimes, but not morning wake up times, and LPN #1 was unable to find any documentation in the record indicating Resident #84's preferred time to get up in the mornings. On 5/24/2017 at 8:05 AM, a review of the CNA Point of Care data noted no information about the time Resident #84 preferred to get up in the mornings. Medical record review revealed Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #211 had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. On 5/22/2017 at 2:53 PM, an interview was completed with Resident #211. Resident #211 stated she was not able to choose the time she was awakened in the morning. They get me up about 8:30 (AM). I prefer 9:00 (AM) or later. On 5/23/2017 at 3:00 PM, an interview was completed with CNA #1 who stated she was familiar with Resident #211. (Resident #211) eats about 7:45 (AM). She likes to sleep in. She will say, I don't feel like it and I want to wait awhile. She gets vital signs each morning around 7:00 (AM) and she will usually say she doesn't want to get up; she wants to wait till after breakfast. Review of the medication record on 5/23/17 at 3:45 PM noted no medications that required vital sign parameters before administering the resident's prescribed medication. On 5/23/2017 at 4:09 PM, an interview was completed with LPN # 2 who stated she was familiar with Resident #211. We get everyone's vital signs every day. We would get Resident #211's vitals each shift. On day shift they would start getting vital signs at 7:00 AM. On 5/24/2017 at 7:48 AM, Resident #211's breakfast tray was noted delivered. On 5/24/2017 at 8:05 AM, a review of the Nursing Assistant Point of Care data noted no information about the time Resident #211 preferred to get up in the mornings. An interview was completed with LPN #1 on 5/24/2017 at 8:05 AM, who stated activities staff ask residents about bedtimes, but not morning wake up times, and that she couldn't find any documentation in the record indicating Resident #211's preferred time to get up in the mornings.",2020-09-01
50,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2017-05-24,371,D,0,1,2T0S11,"Based on facility policy review, observation, and staff interviews, the facility failed to distribute meals in a sanitary manner and failed to disinfect the hands to prevent contamination during meal service on 1 of 3 dining areas observed. The findings included: Review of policy and procedure on Handwashing, dated 10/2014, revealed, .Hands should be washed before starting to work; after break time; after using the rest room; after touching hair, face, or body .after touching anything that might contaminate hands .Sanitizing gel may ONLY be used as an added measure after washing hands to minimize bacteria, but not in place of handwashing . Observation on 05/22/17 at 11:53 AM, during meal service near the 300 hall, revealed Certified Nurse's Assistant (CNA) #5 picked up an uncovered plate of multiple food items from the hot bar (serving line), and carried it to an adjacent dining area across the hallway. Observation of CNA #6 revealed the CNA picked up an uncovered plate of multiple food items and carried the tray across the hallway into another dining area. Continued observation revealed the Dietary Aide (DA) #1 was plating food, without wearing gloves, wiping his face and adjusting his glasses, then touching the plate surfaces with bare fingers and placing resident's food on the plates to be served to the residents. Continued observation revealed DA #1 failed to wash his hands or use hand sanitizer after touching his face or glasses. Observation on 05/24/17 at 7:50 AM, during the breakfast meal service observation near the 300 hall, revealed CNA #8 picked up an uncovered breakfast plate from the tray line, walked across the hallway to the dining room and served Resident #102. Continued observation revealed CNA #9 also picked up an uncovered breakfast plate, carried the plate of food across the hallway to the dining room, and served Resident #105. On 05/24/17 at 8:04 AM, interview with the Dietary Manager (DM) #1, confirmed when staff are walking trays into another room from the serving line, the plated food should be covered. When asked if gloves are required when touching food surfaces, she confirmed that they were.",2020-09-01
51,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2018-07-25,641,D,0,1,M4WC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure an accurate Minimum Date Set (MDS) for one resident (#89) of 43 sampled residents. The findings include: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day MDS dated [DATE] revealed .Section P .physical restraints .used in chair or out of bed .1 (indicating used less than daily) . Observation of the residents on 7/26/18 at 1:02 PM, in the resident's room, revealed resident alert and verbal sitting in wheelchair in room. Continued observation of the resident room revealed no restraint in place to resident or in resident room. Interview with the MDS coordinator on 7/25/18 at 8:50 AM, in the MDS office, confirmed the MDS dated [DATE] was not accurate and the resident had not used a physical restraint.",2020-09-01
52,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2018-07-25,684,D,0,1,M4WC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Lippincott Nursing Center, medical record review, facility documentation review, observation, and interview the facility failed to correctly administer medications for 1 resident (#335) of 6 residents reviewed for unnecessary medications. The findings include: Review of the undated facility policy Administering Medications revealed .3. Medications must be administered in accordance with the orders .4. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Method of identifying the resident checking photograph attached to the electronic medical record .5. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication .6. The following information must be check/verified for each resident prior to administering medications: [REDACTED]. Vital signs, if necessary . Review of the Lippincott Nursing Center 8 Rights of Medication Administration dated 5/27/11 revealed the 8 rights of medication administration included the right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response. Medical record review revealed Resident #335 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making was modified independence indicating the resident had some difficulty in new situations only. Review of facility documentation dated 7/17/18 revealed Resident #335 received the medications of another resident during the 9:00 AM medication pass. Continued review revealed the medications were administered incorrectly to Resident #335 based on mistaken identity. Medical record review of Resident #335's Electronic Medication Administration Record [REDACTED]. Medical record review of a nurses' note dated 7/17/18 and timed 10:30 AM revealed the resident's blood pressure was 196/87; Heart rate was 60 beats per minute; respiratory rate was 18 breaths per minute and the Oxygen saturation (amount of oxygen in the blood) was 98% (percent). Continued review revealed the resident was alert and oriented. Medical record review of a Nurse Practitioner's note dated 7/17/18 revealed .Pt (patient) was given morning meds (medications) that were prescribed to another pt. He had not received his own meds at the time. Medications were reviewed. His own morning blood pressure medication was held due to medicines he received. Pt was seen approx (approximately) 2 hours after receiving medications. He was alert and oriented. No adverse affects have occurred at this time. Discussed with patinet (patient) and daughter that he may have some drowsiness. Vital signs checked per staff and were stable . Medical record review of a nurses' note dated 7/17/18 and timed 1:45 PM revealed the resident's blood pressure was 151/76 and the resident was alert and oriented. Medical record review of nurses' notes dated 7/17/18 from 1:54 PM through 2:30 PM revealed the resident complained of nausea with some .thin watery emesis . Continued review revealed the resident remained alert, oriented and had some complaints of dizziness and sleepiness. Medical record review of a nurses' note dated 7/17/18 and timed 3:00 PM, revealed the resident had no further emesis. Continued review revealed the resident reported he was feeling .a little better . and wanted to go to his doctor's appointment. Medical record review of a nurses' note dated 7/17/18 and timed 3:30 PM, revealed the resident was out of the facility for a doctor's appointment. Medical record review of a Provider Note dated 7/18/18 revealed .patient received wrong medications including [MEDICATION NAME] (medication for [MEDICAL CONDITION]), Requip (medication for restless leg syndrome), [MEDICATION NAME] (medication for depression), Vitamin D (calcium), Risaquad (medication to balance good bacteria in the digestive system), [MEDICATION NAME] (blood pressure medication), and [MEDICATION NAME] (blood pressure medication) . Observations of Resident #335 from 7/23/18 through 7/25/18 revealed the resident was participating in physical therapy and talking with other residents in the hallway. Interview with Resident #335 and the residents' daughter on 7/23/18 at 11:30 AM, in the resident's room revealed the resident had received another resident's medication on 7/17/18. The residents' daughter reported Resident #335 received 2 blood pressure medications, an antidepressant, medication for [MEDICAL CONDITION], and a vitamin in error. Interview with Nurse Practitioner (NP) #1 on 7/24/18 at 3:05 PM, in the Station 4 Chart Room confirmed Resident #335 received another resident's medications on 7/17/18. Further interview revealed the resident complained of nausea for a couple of hours and vomited 1 time. Continued interview revealed the resident's vital signs remained stable, all of the labs were normal and there were no adverse side effects. Interview with Resident #335 on 7/24/18 at 3:41 PM, in the resident's room revealed the resident had received the medications in the hallway as the resident was going to therapy. The resident reported he had gotten sleepy while in therapy, had nausea and vomiting, and was light headed. Interview with Licensed Practical Nurse (LPN) #1 on 7/24/18 at 3:41 PM, in the Infection Control Office revealed she thought Resident #335 came out of room [ROOM NUMBER]. LPN #1 confirmed she gave Resident #335 the medication for the resident occupying room [ROOM NUMBER]. Interview with the Director of Nursing on 7/24/18 at 4:27 PM, in the Station 4 Resident Care Coordinator's Office confirmed Resident #335 received the incorrect medication on 7/17/18 and confirmed the facility failed to follow the facility policy for medication administration.",2020-09-01
53,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2019-06-05,728,D,1,1,PCFO11,"> Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 2 of 24 (Nurse Aide (NA) #1 and NA #2) NAs were removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant CNA after 120 days of taking the NAT program. The findings include: Review of the facility working schedule for the months of February, March, (MONTH) and (MONTH) 2019 revealed NA #1 and NA #2 worked as NA performing the duties of a CN[NAME] Interview with the Director of Nursing (DON) on 6/5/19 at 3:00 PM in the DON's office, the DON was asked if NA #1 and NA #2 had passed the CNA certification exam. The DON stated, No . Interview with the DON on 6/5/19 at 6:03 PM in the conference room, the DON was asked when NA #1 and NA # 2 completed the Nurse Aide Training program. The DON stated .they were in the August/September (2018) class. The DON was asked if NA #1 and NA #2 worked at the facility longer than 4 months without being certified. The DON stated, .yes .they worked up until 2 weeks ago . The DON was asked what duties NA #1 and NA #1 performed. The DON stated, .CNA duties . The DON confirmed the NAs should not have worked longer than 4 months without passing the CNA certification exam.",2020-09-01
54,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2019-06-05,839,D,1,1,PCFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 41 (Licensed Practical Nurse (LPN) #2) nurses reviewed. The findings include: Review of the facility Personnel Action Form for LPN #2 revealed an employment date of [DATE]. Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards on [DATE] revealed LPN #2's license number had an expired status with an expiration date of [DATE]. Review of the Department Allocation Worksheet for the pay period for [DATE] revealed LPN #2 worked at he facility through [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the DON's office, the DON was asked if LPN #2 worked for the facility. The DON stated, .yes .she worked until the middle of (MONTH) (2019) .at that time we discovered her license was expired . The DON confirmed LPN #2 should not have worked on an expired license. The DON was asked who was responsible for license verification. The DON stated, .we are responsible .",2020-09-01
55,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2019-06-05,880,D,0,1,PCFO11,"**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 practices to prevent the potential spread of infection were followed when 3 of 8 (Certified Nursing Assistant (CNA) #1, Physical Therapist Assistant (PTA) #1, and Licensed Practical Nurse (LPN) #1) staff members failed to perform appropriate hand hygiene during contact isolation for Resident #182 and wound care for Resident #181. The findings include: 1. The facility's HANDWASHING policy with a revision date of 4/23/18 documented, .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .in the case of spore forming organisms such as[DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) .require soap and water with friction .PR[NAME]EDURE .Wash hands before and after contact with each patient .and before and after removal of gloves . 2. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITION] Stage 3, Traumatic Subdural Hemorrhage, Diabetes, [MEDICAL CONDITIONS], and Depression. The physician's orders [REDACTED].Strict Isolation-All services provided in room .for [MEDICAL CONDITION] . Observations in Resident #182's room on 6/3/19 at 12:19 PM revealed CNA #1 delivered ice to the resident, removed the gown and gloves, used hand sanitizer, and exited the room. Observations outside Resident #182's room on 6/4/19 at 8:15 AM revealed PTA #1 donned a gown, mask and gloves, and entered Resident #182's room. PTA #1 remained in the room for 37 minutes and exited the room at 8:52 AM without performing hand hygiene. Interview with PTA #1 on 6/4/19 at 8:52 AM outside Resident #182's room, PTA #1 was asked if she washed her hands before she came out of the room. PTA #1 stated, I don't like to use their bathroom . PTA #1 then used the hand sanitizing gel that was on the isolation kit outside the door, and then walked to the therapy gym. Interview with Registered Nurse (RN) #1 on 6/5/19 at 8:03 AM in the conference room, RN #1 was asked why Resident #182 was in isolation. RN #1 stated, [DIAGNOSES REDACTED]. RN #1 was asked what the staff were supposed to do when they entered and exited Resident #182's room. RN #1 stated, They hand wash .the hand gel stuff don't work with the [MEDICAL CONDITION]. They are supposed to wash hands with soap and water coming out of the room. Interview with the Director of Nursing (DON) on 6/5/19 at 8:42 AM in the conference room, the DON was asked if the staff should perform hand hygiene using hand sanitizing gel after they left Resident #182's room. The DON stated, It's not appropriate for the [MEDICAL CONDITION]. 3. Medical record review revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Management notes dated 6/1/19 revealed Resident #181 had extensive [DIAGNOSES REDACTED] (a disease in which calcium accumulates in the small blood vessels of the fat and skin tissue) ulcers, 3 to the left upper arm, 3 to the right upper arm, 1 to the right thumb, 1 to the right hand, and 1 to the right wrist. Observations in Resident #181's room on 6/4/19 at 3:21 PM revealed the following: LPN #1 removed the soiled dressing from Resident #181's right upper arm, cleaned the posterior upper wounds with saline soaked gauze, and then used a cotton swab to apply [MEDICATION NAME] gel, using the same gloves. LPN #1 did not perform hand hygiene between cleaning the wound and applying the clean treatment. LPN #1 placed a saline soaked gauze on the wound to the anterior right upper arm, still wearing the same gloves. LPN #1 did not change gloves or wash her hands between different wounds. LPN #1 removed her gloves, and adjusted the thermostat on the wall. LPN #1 did not perform hand hygiene after removing the soiled gloves. LPN #1 cleaned the [MEDICATION NAME] gel from Resident #181's posterior upper arm wounds with saline soaked gauze, and applied [MEDICATION NAME] One (a dressing used for painful wound management that prevents the outer dressing from sticking to the wound bed) and [MEDICATION NAME] Extra (a moisture retention dressing) using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed her gloves, applied clean gloves, and removed the dressing from Resident #181's right lower arm. LPN #1 did not wash her hands between glove changes and between different wounds. LPN #1 cleaned the wounds to Resident #181's right posterior lower arm using saline soaked gauze and then applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, (abdominal pads (ABD) used for large wounds or wounds needing high absorbency), and conforming gauze dressings using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed the dressings from Resident #181's right wrist and hand, cleaned the wounds with saline soaked gauze, and applied [MEDICATION NAME] One dressing. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 changed her gloves without performing hand hygiene, and applied [MEDICATION NAME] Extra, ABD pads, and conforming gauze to Resident #181's right wrist. LPN #1 did not perform hand hygiene between glove changes. LPN #1 removed the dressing from Resident #181's left upper arm and changed her gloves without performing hand hygiene. LPN #1 cleaned the wounds to the left upper arm with saline soaked gauze, applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, and ABD pad dressings, and wrapped the right upper arm with gauze. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. Interview with the DON on 6/5/19 at 8:42 AM in the conference room, the DON was asked when staff should perform hand hygiene during wound care. The DON stated, In between clean and dirty, I want them to be washing their hands and changing their gloves. The DON was asked if they were supposed to wash their hands when they changed gloves. The DON stated, Yes.",2020-09-01
56,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2017-07-19,157,D,0,1,788Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the Physician of a clinical complication for one resident (#168) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident was rarely/never understood. Medical record review of a nurse note by Registered Nurse (RN) #1 dated 7/18/17 at 8:50 AM revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she noticed the [MEDICATION NAME] was missing around 4 AM. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with LPN #1 on 7/19/17 at 2:55 PM via telephone revealed she worked 7/18/17 from 7 AM to 7 PM and cared for Resident #168. Further interview revealed RN #1 told her at shift change the [MEDICATION NAME] was missing. Continued interview confirmed LPN #1 intended to notify the Physician of the missing [MEDICATION NAME] but failed to do so.",2020-09-01
57,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2017-07-19,225,D,1,1,788Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to investigate injuries of unknown origin for 1 resident (#379) and failed to initiate an investigation in a timely manner for a missing pain patch for 1 resident (#168) of 35 residents reviewed in Stage II. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, revised 11/28/16 revealed .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .An injury should be classified as an injury of unknown source when both of the following conditions are met: (a) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (b) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time .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 . Review of facility policy, Miscellaneous Special Situations, Discrepancies, Loss and or Diversion of Medications, dated 6/2016 revealed .All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed .Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), Consultant Pharmacist and Director of Pharmacy are notified and an investigation conducted. The Director of Nursing leads the investigation .Appropriate agencies, required by state regulation will be notified . Medical record review revealed Resident #379 was admitted to the facility on [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #379 scored 15/15 on the Brief Interview for Mental Status, indicating she was alert and oriented. Continued review of the MDS revealed Resident #379 required extensive assistance of 2 people for transfers and toileting; extensive assistance of 1 person for dressing and bathing; assistance of 1 person for grooming; supervision for eating; and was frequently incontinent of bowel and bladder. Medical record review of nursing notes dated 10/28/16 revealed Resident #379 had bilateral upper extremity skin tears. Continued review of nursing notes dated 11/4/16 revealed the resident had multiple skin tears to bilateral upper extremities. Review of incident reports revealed none were completed for these injuries and no investigations were completed for multiple injuries of unknown origin Interview with the Director of Nursing (DON) on 7/19/17 at 4:30 PM in the conference room, confirmed there were no incident reports for the skin tears which occurred on 10/28/17 and 11/4/17. Continued interview with the DON confirmed there was no investigation into either injury of unknown origin. Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of a nurse note dated 7/18/17 at 8:50 AM by Registered Nurse (RN) #1 revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1 on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she checked the placement of the [MEDICATION NAME] around 4 AM and could not find it. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with RN #3, Unit Manager on 7/19/17 at 2:45 PM in the conference room, when asked her expectation of when staff should notify her of a missing [MEDICATION NAME] on a resident revealed she would expect to be notified immediately. Continued interview revealed she was notified of the missing [MEDICATION NAME] for Resident #168 at approximately 9 AM on this date by LPN #2. Interview with the DON on 7/19/17 at 4:38 PM in the conference room revealed she did not find out about the missing [MEDICATION NAME] until this morning, and an investigation had since been initiated. Continued interview revealed RN #1 did not report the missing [MEDICATION NAME] to the unit supervisor or the DON. Further interview revealed the incident had not been reported to the state agency. Continued interview with the DON confirmed RN #1 did not report the possible misappropriation of narcotic medication in a timely manner and the facility did not report to the State Agency in the required time period.",2020-09-01
58,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2017-07-19,514,D,0,1,788Z11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately document on the Medication Administration Record [REDACTED]. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of the MAR for (MONTH) (YEAR) revealed .CHECK - Patch placement every shift . (narcotic pain medication [MEDICATION NAME]). Continued review revealed documentation the patch was not found on the night shift on 7/17/17. Further review revealed documentation for patch placement on 7/18/17 as RT AC (right [MEDICATION NAME]). Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 2:55 PM via telephone when asked did the resident have a [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) in place on 7/18/17 stated she could not find it. Continued interview when asked about the documentation of checking the patch placement for the [MEDICATION NAME] on 7/18/17 stated I think I put it was on but I should have put not in place. Further interview revealed LPN #1 stated didn't document it right. Interview with the Director of Nursing on 7/19/17 at 4:38 PM in the conference room when asked about LPN #1's documentation regarding the [MEDICATION NAME] placement on the 7/18/17 day shift revealed it was incorrect. Continued interview with the DON confirmed the facility failed to accurately document the [MEDICATION NAME] placement on 7/18/17 day shift for Resident #168.,2020-09-01
59,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2018-08-01,684,D,0,1,D20911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 of 4 (Resident #229, and 230) residents reviewed for bowel incontinence. The findings include: 1. The facility's BM (bowel movement) Protocol policy documented, .Polyethylene [MEDICATION NAME] .17 grams by mouth as needed for constipation if no BM in 2 days .Mix in at least 4oz. (ounces) of water or juice in the morning of the 3rd day .[MEDICATION NAME] 10mg (milligram) suppository rectally as needed for constipation if no results from [MEDICATION NAME] by bedtime of the 3rd day .Fleet Enema rectally as needed for constipation if no results from [MEDICATION NAME] suppository, administer at bedtime on the 4th day .If no BM on the morning of the 5th day notify the physician . 2. Medical record review revealed Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #229 on 7/30/18 at 5:26 PM, in her room, Resident #229 stated, .been here since Wednesday .haven't had a BM in a week . Review of the physician's orders [REDACTED].#229 was on the BM Protocol. Review of the Toileting .BM record revealed Resident #229 did not have a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. Review of the Med (medication) PRN (as needed) record dated 7/1/18 to 7/31/18 revealed Resident #229 did not receive Polyethylene [MEDICATION NAME] on 7/28/18 (the 3rd day) and did not receive the [MEDICATION NAME] rectal suppository on 7/29/18 (the 4th day) as ordered per the BM protocol. Interview with Registered Nurse (RN) #1 on 8/1/18 at 2:28 PM in the Minimum Data Set (MDS) office, RN #1 reviewed the Toileting .BM record for Resident #229, and confirmed that Resident #229 had not had a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. RN #1 reviewed the Med PRN record dated 7/1/18 to 7/31/18, and stated, She didn't get the medication . 3. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#230 was on the BM Protocol. Review of the electronic Toileting .BM record revealed Resident #229 did not have a BM on 7/21/18, 7/22/18, and 7/23/18. Review of the Med PRN record dated 7/1/18 to 7/31/18 revealed Resident #230 did not receive the Polyethylene [MEDICATION NAME] on 7/23/18 (the 3rd day). 4. Interview with the the Nurse Practitioner on 8/1/18 at 11:27 AM in the conference room, the Nurse Practitioner was asked if she had been notified about Resident #229 and 230 not having BMs. the Nurse Practitioner stated, .I was not aware .The expectation is the nurses follow the bowel protocol . Interview with RN #1 on 8/1/18 at 2:38 PM in the MDS office, RN #1 reviewed the Toileting .BM record for Resident #230, and confirmed that Resident #229 had not had a BM on 7/21/18, 7/22/18, and 7/23/18. RN #1 stated, He should have gotten the Polyethylene [MEDICATION NAME] on that third day. Interview with the Director of Nursing (DON) on 8/1/18 at 3:01 PM in the conference room, the DON confirmed that Resident #229 and #230 should have received medication after no BM for 3 days, and stated that it was not appropriate for staff to not follow the bowel protocol.",2020-09-01
60,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2018-08-01,695,D,0,1,D20911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain respiratory equipment in a sanitary manner for 2 of 2 (Resident #16 and 178) sampled residents reviewed for respiratory care. The findings include: 1. The facility's RESPIRATORY MANUAL .Aerosol Therapy policy last revised 7/14, documented, .Cautions .Nebulizer can become contaminated resulting in an infection . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] sulfate .1 ampul ([MEDICATION NAME]) nebulization every 2 hours As Needed SHORTNESS OF BREATH NEBULIZATION .Dx (Diagnosis) .[MEDICAL CONDITION] . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization 3 times per day NEBULIZATION .Dx .[MEDICAL CONDITION] . Observations in Resident #16's room on 7/30/18 at 5:38 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Observations in Resident #16's room on 7/31/18 at 8:30 AM revealed Resident #16 in bed with the nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. The mouthpiece was on the floor. Observations in Resident #16's room on 7/31/18 at 5:09 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Interview with Licensed Practical Nurse (LPN) #1 on 7/31/18 at 5:13 PM on the Grove wing, LPN #1 was asked how the nebulizer tubing, masks, and mouthpieces should be stored. LPN #1 stated, .In a little baggie beside the machine. LPN confirmed the mouthpiece was not on a barrier or covered. 3. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization every 6 hours .NEBULIZATION .Dx .shortness of breath . Observations in Resident #178's room on 7/30/18 at 12:51 PM, and on 7/31/18 at 8:44 AM, 11:36 AM, and 4:56 PM, revealed Resident #178 in bed, with a nebulizer on the bedside table. The tubing and mask were attached and dated 7/25/18. The mask and tubing were uncovered without a barrier. Interview with LPN #1 in Resident #178's room on 7/31/18 at 5:14 PM, LPN #1 confirmed the nebulizer tubing and mask were not covered or placed on a clean barrier and stated, It needs to be covered. Interview with the Director of Nursing (DON) on 7/31/18 at 5:31 PM in the conference room, the DON was asked how the nebulizer masks, mouthpieces, and tubing should be stored. The DON stated, There's a bag they are supposed to be using. and further stated it was unacceptable for them to be out on the bedside table without a cover or a clean barrier.",2020-09-01
61,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2018-08-01,698,D,0,1,D20911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on worksheet review, medical record review, and interview, the facility failed to ensure there was communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #3) sampled residents reviewed for [MEDICAL TREATMENT]. The findings include: The facility's [MEDICAL TREATMENT] Communication Worksheet documented, .ongoing assessment of the patient's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] clinic .Center nurse complete On [MEDICAL TREATMENT] days Pre-[MEDICAL TREATMENT] section of the form prior to appointment .Send with patient to [MEDICAL TREATMENT] clinic .Request the [MEDICAL TREATMENT] clinic to complete the bottom portion of form .return it to the center with the patient . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday (medication administration record) each [MEDICAL TREATMENT] 3 times per week (Tuesday, Thursday, Saturday) . The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and the resident received [MEDICAL TREATMENT] services. Review of the Care Plan dated 1/17/18 revealed [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week. Review of the [MEDICAL TREATMENT] communication forms revealed documentation was not completed on the forms dated 7/17/18, 7/19/18, 7/21/18 and 7/30/18. Interview with the Director of Nursing (DON) on 8/1/18 at 5:09 PM in the conference room, the DON was asked how she expected the nurses to communicate with the [MEDICAL TREATMENT] center. The DON stated, The nurse fills out the pre [MEDICAL TREATMENT] form .it goes with the patient to [MEDICAL TREATMENT] clinic .the [MEDICAL TREATMENT] clinic completes form .the form comes back with the patient .it's scanned into the system . The DON was asked what she expected the nurses to do if the [MEDICAL TREATMENT] center did not send back the form. The DON stated, .I would think they should call the clinic to see if they can get information .keep me informed so I can know the patient is getting what they need . The facility was unable to provide documentation of communication between the [MEDICAL TREATMENT] center and the facility.",2020-09-01
62,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2018-08-01,880,D,0,1,D20911,"Based on policy review, observation, and interview, 2 of 2 (Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1) staff failed to ensure infection control practices were maintained to prevent the potential spread of infection during wound care. The findings include: The facility's HANDWASHING policy, dated 10/1/08, documented, Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #230's room on 7/31/18 beginning at 11:10 AM, revealed CNA #1 assisting RN #2 with wound care. RN #2 cleaned a marker with a bleach wipe and changed her gloves without performing hand hygiene. CNA #1 touched the bed covers, adjusted the bed, and changed her gloves without performing hand hygiene. RN #1 touched the wound with her gloved left hand and changed her gloves without performing hand hygiene. After applying a foam dressing to the wound, RN #1 changed her gloves without performing hand hygiene. After assisting with positioning Resident #230 during wound care, CNA #1 changed her gloves without performing hand hygiene. Interview with the Director of Nursing (DON) on 8/1/18 at 5:58 PM, in the conference room, the DON was asked what nursing staff should do between removing used gloves and donning clean gloves. The DON stated, Perform hand hygiene.",2020-09-01
63,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,607,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and staff interview, the facility failed to timely report an injury of unknown origin per policy to facility administration per facility policy; failed to implement facility policy related to training after an allegation of injury of unknown origin; and the facility administration failed to report the allegation of injury of unknown origin within 2 hours to the State Agency (SA) per facility policy. Failing to implement abuse policies had the potential for abuse events to reoccur and put all 176 residents residing in the facility at risk. Findings include: Review of the facility Abuse, Neglect and Misappropriation or Property, policy, revised 8/24/17, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime. Directly after assuring that the resident(s) involved in the allegation or abuse event is safe and secure, the alleged perpetrator has been removed from the resident care area, and any needed medical interventions for the resident have been requested/obtained, the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON), physician and family or resident's representative of the allegation of abuse or suspicion of crime. The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours. The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegation of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this account. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 with severe cognitive impairment and no behaviors. Resident #10 required extensive assist of 1 person for bed mobility, dressing, and eating, and was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Medical record review of the emergency room Progress Note, dated 12/30/17, revealed a right arm fracture that the physician documented .was not a result of abuse/neglect . Medical record review of a Nursing Progress Note, dated 12/31/17 at 12:08 AM, revealed the .resident returned from the hospital in no acute distress with a right arm splint and arm sling, family at bedside, and pain medication administered with good results . Review of the facility interventions related to the investigation included Abuse Education (MONTH) (YEAR), which included 5 questions related to when to report abuse, signs of abuse, factors increasing the risk of abuse, and common reasons for abuse. Nurses were required to sign they received a copy of the Signature Healthcare's Triage Process. Review of the sign-in sheets for the Abuse Education (YEAR), revealed 137 of 285 listed staff had signed to indicate the training was completed. Review of the facility Positioning Competency, revealed guidelines for assistance for a resident positioning in a bed and chair, and included areas to indicate completion, comments, employee signature, supervisor signature, and yes or no for successful completion. Review of the facility sign-off sheet included completed sign-off for all staff. Upon review of the individual competency sheets revealed multiple sheets were missing dates, evidence the competency was completed, and supervisor signatures. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when Certified Nurse Assistant (CNA) #9 came on shift at 11:00 PM the CNA discovered Resident #10 complaining of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room revealed he did not recall the time of notification of the incident. Further interview confirmed he called the DON on 12/30/17 after the x-ray results were received. Further interview revealed the facility began abuse training immediately on the day of discovery. When CNA #8 stated on 1/03/18 the injury might have occurred during positioning the facility felt the injury was caused by faulty positioning, and the facility began staff competencies for positioning. Since the emergency room physician did not think the injury was related to abuse/neglect the facility moved from an allegation of abuse to care competency. Further interview confirmed a delay in notification resulted in the facility not reporting the injury of unknown origin within 2 hours to the SA per facility policy. The Administrator confirmed the abuse training and positioning competencies for nursing were not completed by the facility after the incident. Interview with the DON on 3/28/18 at 2:00 PM in the Conference Room confirmed the abuse training of when to report abuse was not completed for all staff and the positioning competencies were not completed for all nursing staff at the time of the investigation.",2020-09-01
64,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,609,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review,and staff interview, the facility failed to timely report an injury of unknown origin to the facility administration; and failed to notify the State Agency (SA) within 2 hours for 1 of 8 residents (Resident #10) reviewed for injury of unknown origin. Failing to report allegations of injury of unknown origin could increase the risk to all 176 residents residing in the facility. Findings include: Review of the undated facility Abuse, Neglect and Misappropriation or Property policy, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime .the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON) .of the allegation of abuse .The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #10 with severe cognitive impairment, no behaviors, and requiring extensive assist of 1 person for bed mobility, dressing, and eating. Resident #10 was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Review of the facility documentation report revealed the SA was notified on 12/30/17 at 1:35 PM, 36 1/2 hours after the event. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when CNA #9 came on duty at 11:00 PM Resident #10 complained of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room confirmed there was a delay in notification of the injury of unknown origin to administrative staff resulting in the facility's failure of not reporting the injury within two hours to the State Agency as required and per policy.",2020-09-01
65,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-03-28,880,D,1,0,8HII11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, staff interview, and observation, the facility failed to ensure infection control measures related to the dressing change of a peripherally inserted intravenous catheter (PICC) for 1 of 3 residents (Resident #7) reviewed with PICC lines; and failed to properly utilize hand hygiene during medication administration for 1 of 4 residents (Resident #15) observed for medication administration. Failing to change PICC line dressings had the potential to affect eight residents identified with PICC lines; failing to use hand hygiene could increase the risk of infection, and had the potential to affect all 176 residents in the facility. Findings include: Review of facility Infusion Therapy Procedures dated 2011, was reviewed and revealed .PICC and Midline Catheter dressing changes must be completed at minimum every seven days. Change immediately if: loose, not occlusive, moisture accumulation, drainage, redness, or irritation. Initial dressings will be changed PRN (as needed) if saturated, and 24-48 hours post insertion of Midlines, PICC's . if there is gauze present under the dressing or drainage is noted . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was alert, oriented, and independent with all activities of daily living except assistance of 1 to be off the unit. Medical record review of the nursing admission assessment dated [DATE] revealed the resident was admitted with a right upper extremity PICC line. Medical record review of physician progress notes [REDACTED]. Medical record review of physician orders [REDACTED]. Medical record review of a Daily Skilled Nursing Note dated 12/08/17 revealed .central line dressing scheduled as per staff to be changed . Medical record review of Medication Administration Records, (MAR), dated 11/30/17 through 12/10/17 (11 days) revealed no evidence of a dressing change to the PICC line. Medical record review of Physician order [REDACTED].#7 revealed .discontinue PICC line and reinsert new Midline catheter . Review of a procedure form for Resident #7 dated 12/10/17 revealed .the patient PICC line was out 7 centimeters and the dressing was loose on three sides. A Midline catheter was inserted into the left upper arm with a dressing applied . Medical record review of Physician order [REDACTED]. Medical record review of the MAR for Resident #7 dated from 12/11/17 through 12/26/17 (17 days) revealed no evidence of a dressing change to the Midline catheter. Medical record review of the Comprehensive Care Plan dated 12/11/17, revealed the .resident as at risk for complications related to the use of IV (intravenous) fluids and /or medications with a right upper arm PICC line . Interventions included .apply and check IV site treatment/dressings as ordered . Interview with the Director of Nursing (DON) on 3/28/18 at 2:30 PM confirmed the resident was admitted with a PICC line. Further interview revealed the PICC line became misplaced and a new Midline catheter was placed to continue the antibiotic administration. The DON confirmed the facility failed to have documentation of a dressing change to the PICC line and Midline catheter every seven days as per the facility policy. Review of the facility Medication Administration General Guidelines dated 2007 revealed, .hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. Hand are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 3/27/18 at 8:50 AM revealed Licensed Practical Nurse (LPN) #6 entering the isolation room for Resident #15. LPN #6 donned personal protective equipment (PPE) to include a mask, gown, and gloves. With the help of Rehab #2 the resident was repositioned to allow better access to the resident gastronomy tub ([DEVICE]). LPN #6 removed gloves, donned new gloves, and assessed the [DEVICE] for placement and residual tube feed, changed gloves and administered several medications per the [DEVICE]. LPN #6 then changed gloves and administered prescription eye drops in each eye. LPN #6 took off gloves and reached under the PPE gown and took a large bore needle from a uniform pocket, donned gloves and used the needle to puncture two fish oil capsules, and place the liquid from the capsules in a medication cup. After changing gloves, LPN #6 administered the fish oil through the [DEVICE], changed gloves and administered a subcutaneous injection into the resident's abdomen. After changing gloves, LPN #6 administered a second drop of the prescription eye drop to each of the resident's eyes. LPN #6 then removed the PPE and gloves, washed hands with soap and water before exiting the room. The hand washing prior to exit was the only time LPN #6 completed hand washing or hand hygiene for the entire medication administration. Interview with LPN #6 on 3/27/18 at 9:30 AM on the second-floor hallway confirmed hand hygiene, to include hand washing or alcohol rub, was not used during the medication administration with Resident #15. Further interview revealed LPN#6 was unsure of the facility policy for hand hygiene. Interview with the DON on 3/28/18 at 5:10 PM in the facility Conference Room revealed staff were expected to wash hands or use alcohol rub any time gloves were worn and removed, before and after injections, and before eye drops and [DEVICE] medications. Further interview confirmed nursing staff should not remove items from pockets while in an isolation room.",2020-09-01
66,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,550,D,1,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to provide timely personal care to 1 resident (#83) of 161 residents observed. The findings include: Review of the facility policy, Resident Rights, revised 8/16/18 revealed .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity . Review of the facility investigation dated 2/14/19 revealed Resident #83 had emesis (vomit) on his clothes and the Certified Nurse Aide (CNA) #8, failed to provide care such as changing the resident's clothes. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #83 was totally dependent on 2 people for dressing and mobility. Observation on 4/2/19 and 4/3/19 at 8:39 AM and 8:56 AM, respectively, in Resident #83's room revealed resident in bed, clean no signs and no symptoms of distress noted. Continued observation revealed Resident #83 had just finished eating breakfast and was assisted by staff. Record review of the facility investigation interview with the Chaplain on 2/15/19 revealed the Chaplain was in the dining room on the 4th floor at 2:00 PM and observed Resident #83 had emesis on him. Continued review revealed the Chaplain reported the observation to CNA #8. Record review of the facility investigation interview with CNA #8 on 2/14/19 revealed Resident #83 had vomited approximately 2:15 PM. Continued review revealed CNA #8 took Resident #83 to the room to provide care at 3:20 PM. Interview with the Administrator on 4/3/19 at 3:17 PM in her office revealed Resident #83 had vomited after lunch and the meal schedule for lunch on the 4th floor was from 11:30 PM to 12:30 PM. Continued interview revealed CNA #8 had removed Resident #83 from the dining room and left him in his room still covered in emesis to go down stairs to get a cupcake. Continued interview revealed the lunch trays were not late and at 2:00 PM a valentine's party was going on downstairs. Continued interview confirmed .it really bothered me about the time .",2020-09-01
67,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,641,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 resident (#58) of 59 residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident received insulin injections 7 of the 7 day look back period. Medical record review of Resident #58's Physician order [REDACTED]. Interview with Registered Nurse (RN) #1, responsible for the MDS, on 4/2/19 at 1:45 PM in his office confirmed Resident #58's MDS dated [DATE] was coded to reflect the resident received insulin injections for 7 of 7 days. Continued interview when asked to look at Resident #58's physicians orders, RN #1 confirmed the resident had no orders for insulin. Continued interview revealed It's my mistake, I miscoded the MDS.",2020-09-01
68,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,695,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation and interview, the facility failed to provide necessary care for 3 residents (#34,#95 and #573) of 28 residents receiving respiratory services. The findings include: Review of the facility policy, Departmental (Respiratory Therapy)- Prevention of Infection, revised 2011, revealed .Store the circuit (nebulizer mask) in plastic bag, marked with date and resident's name between uses . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders Sheet dated 2/28/19 revealed .May administer 2 liters of O2 (oxygen) per nasal cannula for SOB (shortness of breath) . Continued review revealed .may oral suction with [MEDICATION NAME] (suction device) as needed . Observation on 4/1/19 at 10:24 AM in Resident #34's room revealed the [MEDICATION NAME] was undated and unbagged and was hanging on top of the humidifier canister. Medical record review revealed Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data set ((MDS) dated [DATE] revealed Resident #95 required oxygen therapy. Observation on 4/1/19 at 10:05 AM in Resident #95's room revealed the unbagged and undated nasal cannula and nebulizer mask were stored on top of the humidifier attached to the wall O2. Observation and interview with the House Supervisor on 4/1/19 at 5:27 PM and 5:30 PM in Residents #34 and #95 room confirmed the [MEDICATION NAME], nebulizer and nasal cannula was unbagged, undated and were stored on top of the humidifier canister. Continued interview confirmed .I see it and will change it . Medical record review revealed Resident #573 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Orders dated 3/1/19 for Resident #573 revealed .[MEDICATION NAME] CONC (concentrate) 1.25 milligrams (MG) 0.5, 1 vial per nebulizer via mask 6 times a day, [DIAGNOSES REDACTED].[MEDICATION NAME] 0.5 MG/2 milliliters (ML) suspension, 1 vial per nebulizer twice a day [DIAGNOSES REDACTED]. Observation on 4/1/19 at 9:37 AM and 12:00 PM in Resident #573's room, revealed the nebulizer mask lying on the bedside table was not bagged or dated. Further observation on 4/1/19 at 2:27 PM in the resident's room revealed the unbagged and undated nebulizer mask was lying on the resident's bed. Interview with LPN #4 on 4/1/19 at 2:49 PM on 400 North Hall confirmed nebulizer masks are kept in bags when not in use. Interview with the Director of Nursing (DON) on 4/3/19 at 11:45 AM in the DON's office confirmed nebulizer masks were to be kept in a plastic bag when not in use.",2020-09-01
69,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,741,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to answer a call light in a timely manner for 1 resident (#72) of 161 residents observed. The findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 3/20/19 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #72 required total dependence by one person for eating. Observation on 4/1/19 at 2:16 PM on the 400 South Hall in room [ROOM NUMBER] revealed Resident #72's call light was activated at 2:16 PM and 2 staff, Licensed Practical Nurse (LPN) #3 and a Certified Nurse Aide (CNA) were on the hall. Continued observation revealed LPN #3 at the medication cart and the CNA using the Kiosk (computer on the wall). Continued observation revealed another CNA walked out of a resident room toward the two staff members, with the activated call light visible. One CNA stated .I already checked and changed 412B . Continued observation revealed a MDS Coordinator walked towards the staff talking and they all looked up and kept talking. Continued observation revealed Unit Manager #3 answered the call light at 2:32 PM. Interview with Unit Manger #3 on 4/1/19 at 2:36 PM on the 400 South Hall when asked what was expected from staff when call lights were activated stated, call lights were expected to be answered when activated.",2020-09-01
70,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,761,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications in 2 of 4 medication storage rooms and on 2 of 6 medication carts. The findings include: Facility policy review, Medication Administration General Guidelines, dated 9/18, revealed .Check expiration date on package/container. No expired medication will be administered to a resident .Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The beyond use dating, which only lists month/year, falls to the last day of that month . Observation of the 200 hall medication storage room on 4/1/19 at 1:00 PM with Licensed Practical Nurse (LPN) #7 revealed the following: 2 multiple dose bottles of Zinc Sulfate (a vitamin/mineral supplement) 220 milligrams (mg),100 count, expired 2/19 and unopened; a multiple dose bottle of [MEDICATION NAME] (a B vitamin supplement) 500mg,100 count, expired 2/19 and unopened; 2 multiple dose bottles of Centravites liquid (a vitamin supplement) 236 milliliters (ml) expired 2/19 and unopened; 3 mutiple dose bottles of [MEDICATION NAME] (a stimulant laxative) 5 mg,100 count, expired 3/19 and unopened; and 4 multiple dose bottles of Senna (a laxative) Syrup 237 ml expired 3/19 and unopened. Interview with LPN #7 on 4/1/19 at 1:16 PM in the 200 hall medication storage room confirmed .that medications should not be used if expired and should be discarded if they are . Observation of the Riberio unit medication storage room on 4/2/19 at 3:00 PM with LPN #8 revealed the following: a multiple dose bottle of Vitamin B1,100 count, expired 3/19 and unopened; 1 tube of [MEDICATION NAME] cream 1% unopened and expired 2/19; and 1 tube of [MEDICATION NAME] cream 1% unopened and expired 9/18. Interview with LPN #8 on 4/2/19 at 3:15 PM in the Riberio medication storage room confirmed .all medications should be used before their expiration date or discarded in the sharps bin here (pointing in the medication room) . Observation of the 200 West medication cart on 4/2/19 at 5:14 PM with LPN #7 on the 200 West hallway revealed a multiple dose bottle of Vitamin B-12 100 mg,130 count, expired 6/26/18. Interview with LPN #7 on 4/2/19 at 5:30 PM on the 200 West hallway confirmed .all expired medications should not be on the cart, should not be used . Observation of the Riberio unit medication cart on 4/3/19 at 2:30 PM with LPN #9 in the Riberio unit medication storage room revealed the following: a multiple dose bottle of Elder Tonic 473 ml expired 12/18 and a multiple dose bottle of D3 (a vitamin supplement) 5000 International Units (IU),100 capsules, expired 2/19. Interview with LPN #9 on 4/3/19 at 2:40 PM in the Riberio unit medication storage room confirmed .that no medications on the cart should be expired . Interview with the Pharmacist on 4/3/19 at 8:00 PM on the telephone confirmed .she reviewed all medication carts and medication storage rooms monthly .she was there on 4/1/19 later in the day at around 5 PM .and she usually removes expired medications by using kitty litter, placing them in sharps boxes, or giving them to the unit manager for disposal .expired medications should not be on the medication carts or in the storage rooms . Interview with the Director of Nursing on 4/3/19 at 8:07 PM in her office confirmed .medication carts and medication storage rooms should not have expired medications .they should be removed and disposed of by taking them back to pharmacy .expired medications should not be used .",2020-09-01
72,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,842,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate and complete record for 1 resident (#58) of 59 residents reviewed related to the Physician Orders and the Tennessee Physician Orders for Scope of Treatment (POST) form. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Medical record review of Resident #58's Physician Order Sheet dated [DATE] revealed .Full Code (meaning a person will allow all interventions needed to get their heart started) . Medical record review of Resident #58's POST form dated [DATE] revealed .Do Not Attempt Resuscitation (DNR/no CPR) (Cardiopulmonary Resuscitation) (allow natural death) . Interview with Unit Manager #1 on [DATE] at 4:20 PM in the Birmingham dining room confirmed Resident #58's POST form and physician orders did not match. Continued interview revealed .the POST form is the most up to date and should match the orders, it should have been caught before now . Interview with the Director of Nursing on [DATE] at 8:39 AM in the 2nd floor Unit Manager's office confirmed .the POST forms and physician orders for residents have to match .",2020-09-01
73,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2019-04-03,921,D,0,1,PJC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide a sanitary environment for 1 resident (#152) of 33 residents reviewed receiving feeding per feeding pumps. The findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].Promote (enteral formula) at 63ml/hr (milliliter per hour) for total of 1336 ml in 24 hours via PEG (percutaneous endoscopic gastrostomy)/pump . Observation on 4/1/19 at 10:43 AM, 2:30 PM and on 4/2/19 at 1:45 PM in Resident #152's room revealed the tube feeding pump, pole and floor with large amount of dried tan debris. Interview with Unit Manager #2 on 4/2/19 at 1:45 PM in Resident #152's room confirmed .that is obviously tube feeding on the pump, pole and floor . Interview with the Director of Nursing on 4/3/19 at 2:40 PM in her office confirmed tube feeding pumps and poles were to be clean.",2020-09-01
76,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-06-13,279,D,0,1,PJSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for side rails and bed alarm for 3 of 23 (Resident #25, 54, and 62) residents reviewed of the 43 resident 's included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive deficit. Review of physician orders [REDACTED]. Review of the fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury. The fall plan of care and the activities of daily living plan of care did not include the use of the side rails as ordered by the resident's physician. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. Licensed Practical Nurse (LPN) #2 verified Resident #25 was only supposed to have the full side rail on the left side of the bed to assist with positioning and he was capable of sitting up on the side of the bed on his own. On 6/14/17 at 12:10 PM, LPN #1 verified the plan of care did not include the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had severe cognitive deficits. The Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicated the resident is at risk.) Review of the physician's orders [REDACTED].#54 had an order for [REDACTED].>The plan of care for falls dated 8/16/16 indicated that the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall related injury by utilizing fall precautions through the next review date of 7/11/17. The plan of care did not address the use of the physician ordered bed alarm. On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. 3. Medical record review revealed Resident #62 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enabler's but did not include the type of side rails (namely full, half or quarter side rails). Resident #62 was observed in bed with bilateral full side rails up on both sides of the bed on 6/11/17 at 4:20 PM; on 6/12/17 at 3:39 PM and 3:53 PM; on 6/13/17 at 7:40 AM, 8:41 AM, and at 1:39 PM; and on 6/14/17 at 9:36 AM. During the observation on 6/12/17 at 3:39 PM, LPN #4 verified the resident always used full side rails when the resident was in bed. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated Resident #62 was not cognitively capable of using the side rails as enabler's and stated the bilateral full side rails were put into place at the request of the resident's family.",2020-09-01
77,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-06-13,309,D,0,1,PJSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure proper positioning for dining for 1 of 1 (Resident #44) sampled residents reviewed for positioning during dining. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, no behaviors, and required extensive to total staff assistance for activities of daily living. Observations in the Birmingham 4th floor dining room on 6/11/17 at 5:57 PM, and 6/13/17 at 12:51 PM, revealed Resident #44 was seated at the table for a meal in a low scoot chair. Resident #44's tray was on the table in front of him, and he had to reach up to the table due to poor positioning. Interview with Licensed Practical Nurse (LPN) #6 on 6/13/17 at 12:55 PM, in the 4th floor dining room, LPN #6 was asked whether it would be better for Resident #44 if he was positioned a bit higher during meals. LPN #6 stated, .it (the scoot chair) could be lifted up . LPN #6 was asked whether she thought it looked too high for the dining table. LPN #6 stated, I do . Interview with Occupational Therapist (OT) #1 on 6/13/17 at 1:05 PM, at the 4th floor nurses' station, OT #1 was asked whether the chair was too low for the table. OT #1 stated, Yes .",2020-09-01
82,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-05,580,D,1,0,FKIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the Physician of a change in condition for 1 of 5 residents (Resident #1) reviewed. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician ordered ventilator settings for Resident #1 revealed: Mode- SIMV (synchronized intermittent mechanical vent), and Rate- 12 (minimum number of respirations per minute). Continued medical record review of a Respiratory care flow sheet revealed on 6/6/18 at 3:35 AM, 7:34 AM, 10:53 AM, 3:13 PM, and 7:00 PM the ventilator mode for Resident #1 was documented as being SIMV and the Set rate was 12. Continued review revealed at 3:13 PM the total respiratory rate had elevated to 21, and then to 28 at 7:00 PM which indicated Resident #1 was tachypnic (increased respirations). Continued review revealed at 11:05 PM on 6/6/18 Registered Respiratory Therapist (RRT) #1 changed Resident #1's ventilator mode to Assist Control which was an increase in ventilator support and also changed the respiratory set rate to 18. Continued review of the medical record revealed no documented notification to the Physician of Resident #1's change in condition. Interview with Director of Respiratory Services on 7/3/18 at 9:10 AM in the conference room confirmed Resident #1 had a change in condition on 6/6/18 which required an increase in ventilator support and RRT #1 failed to notify the Physician of the change in the resident's condition. Telephone interview with RRT #1 on 7/3/18 at 1:50 PM revealed on 6/6/18 Resident #1 trended tachypnic and he followed the respiratory algorithm to adjust the ventilator settings without first notifying the Physician of the change in the resident's condition.",2020-09-01
83,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-05,684,D,1,0,FKIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to administer antibiotic medication per physician order and per facility policy for 1 of 3 residents (Resident #3) reviewed receiving antibiotic medication. Findings include: Review of the facility policy, Medication Administration, dated 5/16, revealed .Procedures .Medication Administrations .Medications are administered with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders for antibiotic medication revealed the following: 1. On 6/6/18 [MEDICATION NAME] 500 milligrams (mg) every 12 hours for 7 days for [DIAGNOSES REDACTED]. 2. On 6/12/18 [MEDICATION NAME] ([MEDICATION NAME]/Clavulanic Acid) 875 mg by mouth three times daily for 7 days for [DIAGNOSES REDACTED]. 3. On 6/19/18 [MEDICATION NAME] 3.375 gram infuse intravenously every 6 hours for 10 days for [DIAGNOSES REDACTED]. Medical record review of the 6/2018 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] was administered for 12 of 14 doses ordered from 6/7/18 at 12:01 AM through 6/12/18 at Noon. The facility failed to administer 2 of the 14 ordered doses. 2. [MEDICATION NAME] was administered for 19 of the 21 doses ordered from 6/12/18 at 8:00 PM through 6/18/18 at 8:00 PM. The facility failed to administer 2 of the 21 ordered doses. 3. [MEDICATION NAME] was administered for 36 of 40 doses ordered from 6/20/18 at 12:01 AM through 6/28/18 at 6:00 PM. The facility failed to administer 4 of the 40 ordered doses. Interview with the Unit B2 Manager on 7/3/18 at 10:50 AM in his office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Interview with the Director of Nursing on 7/3/18 at 11:18 AM in her office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Further interview confirmed the facility failed to follow the facility Medication Administration policy and failed to administer antibiotics per the physician orders.",2020-09-01
84,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,550,D,0,1,565T11,"Based on observation and interview, the facility failed to serve meals to residents seated at the same table during 3 separate observations of the mid day meal. Findings include: Observation of the mid day meal on 7/23/18 from 11:40 AM-12:42 PM in the B3 dining room revealed 3 residents were seated at a table. 1 resident had a meal tray and the other 2 residents were not served a meal tray until 21 minutes later. Continued observation revealed 4 other residents were seated at a table and a Certified Nurse Assistant (CNA) #3 was assisting 1 resident while the other residents sat at the table. Continued observation revealed the last resident seated at the table was served his meal tray 1 hour after the 1st resident seated at the table was served. Interview with CNA #3 on 7/23/18 at 12:43 PM in the B3 dining room stated there were 3 carts delivered to the unit and not all of the trays came to the dining room residents at the same time. Further interview confirmed the last residents meal tray was on the 3rd cart and the resident had to wait to be served his meal until after the other 3 residents had received their meal. Observation of the mid day meal on 7/24/18 from 11:40 AM-12:20 PM in the B3 dining room revealed the 1st meal cart was delivered at 11:43 AM. 4 residents were seated at a table and 1 resident was served her meal tray while the other 3 residents were not served. Continued observation revealed the 2nd meal cart was delivered at 12:08 PM and the 2nd resident at the table was served his tray while the other 2 residents were dozing in their wheelchairs. Further observation revealed the 3rd meal cart was delivered at 12:22 PM and the other 2 residents received their trays. Interview with the Director of Nursing (DON) on 7/24/18 at 4:17 PM in the hall by the conference room was notified of the mid day meal dining observations on 7/23/18 and 7/24/18, and the concerns with all diners seated at a table together and not served their meal trays at the same time. The DON was asked if she was aware of the concern and stated, I didn't realize it was a concern to that extent. Interview with the Administrator on 7/25/18 at 7:15 AM in the conference room stated, I think we need to ask the resident if it's OK that others are eating, or take them for a walk or something. That would take care of the dignity thing. Is that right? The Administrator was asked if he knew what the Regulations said and stated, All diners at the table are to be served at the same time. That's the answer. Further interview confirmed cognitively impaired residents may not understand why others are eating and they are not. The Administrator confirmed the facility failed to serve all residents seated at the table at the same time. Observation on 7/23/18 in the R1 dining room during the mid- day meal a at pproximately 11:40 AM revealed the lunch trays were passed. Further observation revealed Resident #111 was seated at the table with 3 residents. Further observation revealed CNA #6 was assisting another resident while Resident #111 waited at the table to be assisted. Further observation revealed Resident #111 was assisted with his meal at 12:20 PM. Interview with CNA #6 on 7/23/18 at 12:40 PM in the R1 dining room revealed 4 CNA staff were assisting with dining. Further interview revealed the dining carts were not organized to the way the residents were seated. Therefore some residents got served first while others waited to be served. Interview with the DON on 7/25/18 at 5:25 PM in her office revealed staff should serve the group at the same time. Further interview confirmed we should have staff accommodating patients as they are seated at the table.",2020-09-01
85,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,558,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep a bathroom call light in reach for 1 of 18 bathrooms ( room [ROOM NUMBER]) observed on the R1 unit. Findings include: Observation on 7/23/18 at 3:47 PM in the bathroom in room [ROOM NUMBER] revealed the call light on the right side wall was tied to the bar of the metal shelf connected to the wall. Observation and interview with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:50 PM in the bathroom in room [ROOM NUMBER] confirmed the facility failed to have a call light in reach. Further interview revealed I don't know why it is like that. Interview with the Director of Nursing on 7/25/18 at 4:55 PM in conference room revealed she expected the bathroom call light to be accessible to all residents.",2020-09-01
86,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,584,D,0,1,565T11,"Based on observation and interview the facility failed to maintain clean and sanitary resident equipment for 1 of 24 sampled residents (Resident #117) reviewed. Findings include: Observation of Resident #117 on 7/23/18 at 10:48 AM in the B3 day room revealed he was seated in a wheelchair. Continued observation revealed the left side of the wheelchair had rusted areas on the lower metal bar. Continued observation revealed the wheelchair frame was dusty, dirty, and had white spotted debris over the metal frame, foot rest and handles. Observation on 7/23/18 at 11:47 AM in Resident #117's room revealed the resident had dried debris and dirt on the upper side rails. Continued observation revealed there were light blue pads attached to the side rails by Velcro tabs and had black marks and spotted brown and yellow debris on them. Observation on 7/24/18 at 9:10 AM in Resident #117's room revealed the side rails and light blue pads remained unchanged from the observation the day before. Continued observation revealed the resident's wheelchair was stored in the bathroom and the rust, dirt, and white spotted debris was still present. Observation and interview of Resident #117's bed and wheelchair on 7/24/18 at 11:30 AM with Housekeeper #3 in the resident's room revealed dried debris on the side rails, dirty blue padding to the upper side rails and the wheelchair in the bathroom with rusted areas, and it was dirty with debris and white spots on the metal frame, foot rest and handles. Interview with Housekeeper #3 when asked when resident wheelchairs were cleaned stated, I'm not sure. The Housekeeper was asked when resident beds were cleaned and stated, Everyday. Continued interview with the Housekeeper when asked when resident padding was cleaned stated, They should be wiped down every day but if the resident is in the bed, it's kind of hard. The Housekeeper was shown Resident #117's wheelchair in the bathroom and stated, It don't look too good. It could use a rag or two. It needs to be wiped down. The Housekeeper was asked again how often resident wheelchairs were cleaned and stated, We took the wheelchairs down and hosed them down and wiped them up. When asked when that was, the Housekeeper stated, It's been quite a while. (MONTH) or (MONTH) of last year. The Housekeeper confirmed the side rails, blue pads and wheelchair should have been cleaned with a disinfectant. Interview with the Housekeeping Director on 7/24/18 at 12:12 PM in Resident #117's room when asked how often deep cleaning was performed on residents wheelchairs stated, Everywhere else it's always been the 3rd shift (Certified Nurse Aides) that are supposed to clean the wheelchairs. It's not happening here. Continued interview revealed the Housekeeping Director stated, We pressure washed every wheelchair last (MONTH) and as needed and when a resident is discharged . The Housekeeping Director was shown the dirty blue side rail pads (Housekeeper #3) had already cleaned the dried debris on the side rail) and the resident's wheelchair in the bathroom and stated, It definitely needs to be cleaned. The beds are cleaned on a daily basis and dusted underneath. We deep clean them every month, as needed and upon discharge. The pads should be cleaned daily or change them out. I do audits on rooms but beds are not included on it. I'm going to add it now though. Stated, I'm going to get with the maintenance man and see if we can get the rust off of here and clean this wheelchair up. The Housekeeping Director confirmed the facility failed to maintain Resident #117's equipment in a clean and sanitary manner.",2020-09-01
87,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,604,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed failed to obtain a physician's order, failed to assess, failed to obtain a consent, failed to monitor and failed to re-evaluate the need for restraints for 1 of 23 (Resident #117) residents reviewed; failed to obtain a medical diagnosis, failed to monitor, and failed to re-evaluate the need for a restraint for 1 of 23 (Resident #111) residents reviewed. Findings include: Review of facility policy Use of Restraints undated, revealed, .Restraints only may be used .after consideration, evaluation, and the use of all other viable alternatives. All residents have the right to be free from restraint .PHYSICAL RESTRAINTS: are defined as any manual method, or physical .device, .or equipment attached or adjacent to the resident's body that an individual cannot remove easily and which restricts the resident's freedom of movement or normal access to his/her body . Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Medical record review of Resident #117's electronic medical record revealed no physician's orders for a restraint or positioning device. Medical record review of recapitulation Physician's Orders for (MONTH) (YEAR) revealed no orders for a restraint or positioning device. Medical record review revealed no restraint assessment, no restraint consent, no monitoring of a restraint and no re-evaluation of the restraint. There was no documentation that a lesser alternative to a restraint had been attempted prior to the use of the tilted wheelchair and belts. Interview with Licensed Practical Nurse (LPN) #2 and Unit Manager on B3 on 7/25/18 at 10:45 AM in his office was provided Resident #117's chart and asked where the documentation was regarding the resident's restraints and stated, They're not restraints, they use them for positioning. Those belts are for positioning and they don't prevent him from doing anything he can do without the belt. Continued interview with LPN #2 when asked why use the belts at all and stated, They are for positioning. We were told by MDS and care plan committee they weren't restraints due to his [DIAGNOSES REDACTED]. upright in the wheelchair he will flop over. (Demonstrated leaning forward over his knees). He has [DIAGNOSES REDACTED] in his legs sometimes and they go straight out, so he has the lap belt or he would slide right out of the chair. When asked where the assessment for the restraints, and documentation of their release every 2 hours, medical diagnosis, consent, and documentation of the least restrictive restraints previously used on the resident he stated, There is not any documentation for any of that, because we didn't do it, we used the chair with those belts for positioning. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in LPN #2's office with LPN #2 present stated, We were using the chair with the belts for positioning to prevent falls. When asked if the resident had had a fall LPN #2 stated,He has not. Continued interview revealed the MDS Coordinator stated, If he can't stand up then its not a restraint. Assistant Director of Nursing (ADON) #2 entered the office at 12:05 PM and all 3 staff were asked if other residents with a [DIAGNOSES REDACTED].? The staff stated they were not sure. The staff was asked if the resident could voluntarily move his head backward and forward was the chest belt preventing him from moving voluntarily and ADON #2 and LPN #2 both said Yes. The staff was asked if the resident was receiving his highest practicable well being by being restrained by tilting him back, and having a chest and lap belt if he could only move his right arm a little bit and his head? The ADON and the LPN agreed the chest belt did prevent Resident #117 from moving freely. Further interview revealed when asked if a wheelchair with a chest and lap belt was the best and least restrictive alternative for Resident #117, LPN #2 stated, It's definitely not the best chair for him. I referred him to therapy a year ago for a different chair and positioning but nothing changed. The ADON stated, The chair is not appropriate. LPN #2 stated, He is supposed to be up in the chair 3 times a week for 3 hours max (maximum) because his skin is so fragile. ADON#2, the MDS Coordinator and LPN #2 confirmed there was no physician's order or any documentation in the resident's medical record indicating the tilted wheelchair, chest belt and lap belt were to be used for positioning for Resident #117. Interview with the Occupational Therapist (OT) on 7/25/18 at 12:55 PM in the Physical Therapy Department confirmed Resident #117 was last seen by therapy on 3/29/17 per request of the nursing staff. Continued interview revealed the resident was evaluated for contracture management only. The OT was asked if they re-evaluate resident equipment like specialized wheelchairs every so often after the resident has used it for a while and stated No, we're not allowed to. We have to wait for a referral from nursing. If they need to be re-evaluated, nursing sends the request on an orange request form with the specific things they are concerned about. Continued interview revealed the OT was asked when they recommend a specific wheelchair with chest and lap belt restraints, did the physician have to approve it first, and the OT stated, We write the order for what we think is best for the resident and the physician comes behind us and signs off on it. When the OT was asked if that order was supposed to be on the active order sheet if the resident is still using it he stated, Yes, it should be in the chart. Further interview revealed when the OT was asked if he could check the electronic record to determine when and how long Resident #117 had the wheelchair and restraints, the OT looked in the computer and stated, No, I can't tell how long he's had it. When (named corporation) took over the facility in (YEAR) we didn't have access to the previous electronic records. Continued interview revealed the OT was asked if there were other residents in the facility with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to obtain a physician's [DIAGNOSES REDACTED].#117; failed to assess the resident for the use of restraints and/or positioning; failed to obtain a consent for restraints; failed to document the release of the restraints; failed to evaluate the ongoing use of restraints, and failed to document the least restrictive alternative for restraints for the resident. Continued interview with the DON confirmed there was no documentation in Resident #117's medical record regarding the use of a chest belt or lap belt for positioning purposes. Findings include: Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the Cognitive Skills for Daily Decision Making score 3 indicating severe impairment. Medical record review of the Quarterly MDS dated [DATE], Quarterly MDS dated [DATE] and Annual MDS dated [DATE] revealed .Section P. - Used in chair or out of bed Trunk restraint 1(Used less than daily) . Medical record review of the physician orders dated 1/6/16 revealed .Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM),1600 (4 PM). Medical record review of the Medication Administration Record [REDACTED].Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM) ,1600 (4 PM). Observation of Resident #111 on 7/23/18 at 12:20 PM in R1 dining room revealed the seat belt attached to the wheelchair and buckled around his waist. Interview with LPN #4 on 7/25/18 at 8:31 AM in the hallway near the residents room revealed the seat belt was used to prevent the resident from sliding out of his wheelchair onto the floor. Further interview confirmed LPN #4 failed to adjust his seat belt as ordered. Interview with the Nurse Practitioner on 7/25/18 at 8:40 AM at the R1 nurse station revealed if Resident #111 was in his wheelchair during the day he must have seat belt for safety. Further interview revealed the reason for the seat belt is for safety. It gives him freedom but keeps him safe. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station Further interview confirmed no documentaion was found for the placement and release of the safety belt. Interview with the Director of Nursing on 7/25/18 at 2:15 PM in her office revealed confirmed that there is no medical [DIAGNOSES REDACTED]. Further interview revealed there was no place for the CNA's to document on the MAR. Telephone interview with the Medical Director on 7/25/18 at 2:53 PM revealed he did not confirm the medical [DIAGNOSES REDACTED].",2020-09-01
88,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,609,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation and interview the facility failed to report an allegation of abuse to the state agency within the required 2-hour time frame for 3 of 6 sampled residents in 1 of 3 allegations of abuse (Resident #118, Resident #71, and Resident #151) reviewed. Findings include: Review of facility policy Abuse, Neglect & Misappropriation or Property reviewed 11/6/17 revealed, .The Facility Administration is the Facility's designated Abuse Coordinator and any questions regarding the interpretation or implementation of the policy should be referred back to him or her .an alleged violation involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Medical record review revealed Resident #118 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 for Resident #118 indicating moderate cognitive impairment. Continued review revealed behaviors exhibited of verbal symptoms toward others. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed a BIMS score of 99 for Resident #71 indicating severe cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a 5-day admission MDS dated [DATE] revealed a BIMS score of 15 for Resident #151 indicating no cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Review of a facility investigation involving Resident #118, Resident #71 and Resident #151 on 7/15/18 at 5:30 PM revealed an allegation of resident to resident abuse. Continued review revealed the facility reported the allegation of abuse on 7/16/18 at 7:43 PM. Interview with the Director of Nursing (DON) on 7/25/18 at 12:10 PM in the DON's office confirmed the facility failed to report the allegation of abuse for Resident #118, Resident #71, and Resident #151 to the state agency within the required 2-hour time frame.",2020-09-01
89,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,641,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to accurately assess the use of restraints for 1 of 2 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's office on the 3rd floor was asked why the use of a restraint was not captured on the Quarterly MDS for Resident #117 and stated, because we were using the chair with the belts for positioning to prevent falls not as a restraint. Continued interview confirmed there was no documentation in the resident's medical record the restraints were used for positioning purposes. The facility failed to accurately assess the use of restraints for Resident #117.",2020-09-01
90,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,656,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a comprehensive care plan for positioning and restraints for 1 of 23 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Continued review revealed the resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Medical record review of the comprehensive care plan for Resident #117 revised 5/26/18 revealed no identified concern related to restraints or positioning, and no related interventions. Interview with Licensed Practical Nurse (LPN) #2, Unit Manager, on 7/25/18 at 10:45 AM in his office was provided Resident #117's chart and asked where the documentation was regarding the resident's restraints and stated, They're not restraints, they use them for positioning. The LPN was asked to review the resident's care plan for positioning and/or restraints and interventions and stated, There is no restraint care plan because those belts were for positioning. Continued interview when the LPN was asked about care of the resident related to the chest belt, lap belt and tilted back wheelchair he stated, There should be a positioning care plan for all of that. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's office on the 3rd floor confirmed there was no positioning care plan for Resident #117, because we were using the chair with the belts for positioning to prevent falls. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to create a positioning care plan with specific interventions for Resident #117, and failed to create a restraint care plan for the resident.",2020-09-01
94,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2018-07-25,880,D,0,1,565T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #87 and Resident #1) reviewed related to dating of oxygen tubing for Resident #87 and Resident #1, and dating of humidified water canister for Resident #1, and storage and dating of a [MEDICATION NAME] (suctioning instrument) for Resident #1. Findings include: 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 a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Medical record review of the physician's orders [REDACTED].oxygen at 5 liter / per minute via mask. As needed. Dx (diagnosis) lethargic, low blood pressure .3/16/18 Treatment/Procedure suction with [MEDICATION NAME] PRN (as needed) for increased secretions . Observation on 7/23/18 at 10:27 AM in Resident #1's room revealed the [MEDICATION NAME] connected to tubing hanging on the wall uncovered and undated. Further observation revealed nasal cannula uncovered and undated. Further observation revealed humdified water canister connected to oxygen port on wall dated 5/16/18. Interview and observation with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:39 PM in Resident #1's room confirmed the the [MEDICATION NAME] with tubing and nasal cannula was uncovered and undated. Further observation and interview revealed the date on the humidified water canister was 5/16/18. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station confirmed the tubing was suppose to be dated and changed weekly by the nurses. Further interview confirmed the facility failed to date, and cover the respiratory equipment and replace the humidified water canister. Medical record review for Resident #87 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #87's Annual MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 14 which indicated the resident was cognitively intact. Further review of the MDS section O revealed the resident was receiving oxygen therapy. Review of the (MONTH) (YEAR) physician's orders [REDACTED].change oxygen tubing weekly every Wednesday night . Review of the (MONTH) (YEAR) medication administration record (MAR) for Resident #87 revealed .change oxygen tubing weekly every Wednesday night . Observation of Resident #87 on 7/23/18 at 10:55 AM and 3:43 PM, and on 7/24/18 at 8:16 AM in the resident's room revealed the resident's oxygen tubing was not dated. Interview with RN #1 on 7/24/18 at 8:24 AM in Resident #87's room confirmed the oxygen tubing was not dated. RN #1 picked up the oxygen tubing and stated the tubing and canisters are changed and dated at the same time, there's usually a piece of tape on the tubing with a date on it but I don't see one on his. Further interview confirmed oxygen tubing was to be changed and dated every 7 days. Interview with the Assistant Director of Nursing (ADON) #1 on 7/24/18 at 8:30 AM in the 400 hall confirmed oxygen tubing and canisters were to be changed and dated weekly. Interview with the Director of Nursing (DON) on 7/25/18 at 8:45 AM in the conference room confirmed oxygen tubing should be dated. The DON stated there was no policy for dating oxygen tubing, it's documented on the MAR every Wednesday and the oxygen tubing should be dated.",2020-09-01
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 (Resident #84) was wet and needed to be changed. Patient (Resident #84) stated (Named CNA #1) answered her call light. Only changed her (Resident #84) under pad and brief but did not change her wet bottom sheet .7/22/19---I (ADON) received a call from (Named Resident #84's daughter) .She (Named Resident #84's daughter) stated that her mother (Resident #84) had told her (Named Resident #84's daughter) about the incident of being wet and stated that .when (Named CNA #1) made her first round on 11-7 shift that she (CNA #1) asked (Resident #84) why she (Resident #84) lied on her (Resident #84) and said she (CNA #1) did not change her (Resident #84) appropriately .I (ADON) spoke with (Named Resident #84) who did state all of the above documented that occurred. She (Resident #84) also reported, that (Named CNA #1) cared for her (Resident #84) last night .stated when she (CNA #1) came in to check her (Resident #84), she (CNA #1) leaned over and kissed her (Resident #84) on the lips and stated 'I (CNA #1) still love you (Resident # 84)'. (Named Resident #84) stated that made her feel uncomfortable .and 'I (Resident #84) don't know why this has happened .I (Resident #84) did not lie on her (CNA #1)' .7/23/19 .(Named CNA #1) states she did change (Named Resident #84) properly. When I (ADON) questioned about her (CNA #1) accusing (Named Resident #84) of lying, she (CNA #1) stated, 'Yes, I did ask her why she (Resident #84) lied on me (CNA #1)' .Also questioned (CNA #1) about the kissing (Named Resident #84) on the lips. (Named CNA #1) stated, 'I (CNA #1) would never kiss my patients on the lips, but I do hug and kiss them on the cheek every night I work . The ADON confirmed that she had written this timeline and signed the document. Interview with Resident #84 on 7/31/19 at 8:32 AM, in her room, Resident #84 was asked if CNA #1 often kissed her on the cheek. Resident #84 stated, She kissed me on the mouth. Resident #84 was asked again if CNA #1 sometimes kissed her on the cheek. Resident #84 stated, No. Interview with CNA #1 on 7/30/19 at 7:35 AM, in the Conference Room, CNA #1 was asked what happened with Resident #84. CNA #1 stated, I went in the room and asked the patient, I'm trying to think what I said .asked patient why she (Resident #84) said I didn't change her and .why she (Resident #84) said I didn't change the bottom sheet. CNA #1 was asked if she kissed Resident #84. CNA #1 stated, On the cheek. CNA #1 was asked if she asked Resident #84 if she lied on her. CNA #1 stated, I don't recollect. Interview with the ADON on 7/30/19 at 1:46 PM, in the Conference Room, the ADON was asked about the incident with CNA #1 and Resident #84. The ADON stated, (Named Resident #84) said she (CNA #1) leaned down and hugged her (Resident #84) and kissed her on the lips and she (Resident #84) did not feel comfortable with that .Tuesday morning I came in and talked to her (CNA #1) about her (CNA #1 stating Resident #84) lying on her. She (CNA #1) admitted that she had said that .I then talked about the kiss .(CNA #1) said she .hug them and kiss them (residents) on the cheek . The ADON was asked when she typed up the untitled timeline. The ADON stated, .I completed it yesterday when you asked for it . The ADON was asked if any other residents were asked about CNA #1. The ADON stated, I did not. The ADON was asked if any staff were questioned about CNA #1. The ADON stated, I did not question any staff. The ADON was asked if Resident #84 had ever accused staff falsely. The ADON stated, Not that I'm aware of . The ADON was asked according to their policy, what should be done when there is an allegation of neglect or abuse. The ADON stated, An investigation should be conducted immediately. Interview with the Director of Nursing (DON) on 7/30/19 at 2:59 PM, in the Conference Room, the DON was asked if an investigation had been done about the incidents with Resident #84. The DON confirmed there was no investigation.",2020-09-01
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 the South Nurse's Station, LPN #1 was asked what type of communication goes with Resident #340 to [MEDICAL TREATMENT]. LPN #1 stated, We (staff) fill out a form called the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 was asked did Resident #340 [MEDICAL CONDITION] which required contact isolation. LPN #1 stated, Yes. LPN #1 was asked if the information concerning [MEDICAL CONDITION] was included on the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 stated No, but I guess it (MRSA information) should be . LPN #1 was asked if that information was given today in verbal report to [MEDICAL TREATMENT]. LPN #1 stated, No . Interview with the DON on 7/31/19 at 2:48 PM, in the Conference Room, the DON was asked if isolation status should be included on the [MEDICAL TREATMENT] Communication Form. The DON stated, Just because it (isolation status) is not on the form doesn't mean they ([MEDICAL TREATMENT] staff) don't know. The DON was asked how can isolation status be communicated and not overlooked. The DON stated, I will have to add it (isolation status) to this form. Interview with LPN #2 on 8/1/19 at 9:50 AM, in the Conference Room, LPN #2 was asked if she was over Infection Control. LPN #2 stated, Yes. LPN #2 was asked should the [MEDICAL TREATMENT] Communication Worksheet reflect that the patient is in Isolation. LPN #2 stated, Yes .",2020-09-01
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 residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No. 2. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 10/6/17 revealed Resident #76 had falls noted since admission, and fall prevention interventions included placing 2 fall mats at bedside when Resident #76 was in bed. Observations in Resident #76's room on 12/11/17 at 2:37 PM and 3:11 PM, and on 12/13/17 at 7:50 AM, revealed Resident #76 lying in her bed. There were no fall mats at the bedside. Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 7:55 AM, in Resident #76's room, LPN #1 confirmed there were no fall mats at the bedside for Resident #76. LPN #1 went to the nurses' station, reviewed the care plan, and confirmed there should be fall mats at the bedside.",2020-09-01
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. 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 residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No.",2020-09-01
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 quarterly MDS dated [DATE] revealed Resident #3 was severely cognitive impaired and required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #3's care plan dated 10/17/18 revealed the resident was care planned for resistance to care during ADLs and smacks and yells out when care was provided. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 was severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident had episode of physical behavioral directed toward others. Continued review revealed the resident required total assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #4's care plan revealed the resident was at risk for episodes of [MEDICAL CONDITION] and changes in behaviors and moods. Review of a facility investigation dated 12/14/18 revealed Certified Nursing Assistant (CNA) #1 notified Licensed Practical Nurse (LPN) #1 the morning of 12/14/18 of an allegation of abuse, which occurred on the day shift of 12/13/18 (prior day). Further review revealed CNA #1 alleged she witnessed CNA #2 abuse 4 residents during care. Continued review revealed CNA #1 alleged CNA #2 held her hands over the mouth of Resident #2 and #4 and hit Resident #1 in the head with a pillow because he called the CNAs the B word. Further review revealed CNA #1 stated, during ADL care for Resident #3, CNA #2 was holding the resident's hands tightly because the resident was trying to put her hands in the incontinent episode and when Resident #3 started to cry CNA #2 put her hand over the resident's mouth and told her to be quiet. Continued review revealed CNA #1 stated she was afraid to report the incidents, but after she thought about it over night she reported the incidents to LPN #1. Further review revealed CNA #2 denied the incidents, but she was terminated on 12/18/18 due to .recent investigation has determined that on Thursday, (MONTH) 13th while performing her CNA assignments (CNA #2) provided care and assistance which did not meet an acceptable standard of care . Continued review revealed . a recent investigation determined (CNA #1) observed a number of inappropriate interactions demonstrated by a fell ow coworker (CNA#2). Standard practices were not followed as there was a delay in reporting these events . Interview with CNA #1 on 1/7/19 at 1:30 PM, in the Director of Nursing's (DON) office, confirmed the CNA was aware she was required to report any allegation of abuse immediately. Telephone interview with CNA #2 on 1/7/19 at 1:45 PM revealed the CNA denied the abuse occurred. Interview with the Administrator on 1/7/19 at 3:15 PM, in the Administrator's office, confirmed CNA #1 was aware she should have reported the allegation of abuse immediately, but failed to do so.",2020-09-01
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
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,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. November 2017 - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December 2017 - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January 2018 - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February 2018 - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March 2018 - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Telephone interview with Resident #44's Physician on 3/7/18 at 1:50 PM, confirmed he had standing orders in place to address constipation. The physician stated he had a standing order for laxative of choice, which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Further interview confirmed [MEDICATION NAME] and [MEDICATION NAME] had not actually been documented on the routine orders for Resident #44 and the nurses would have had to contact him for further orders. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed the facility failed to follow Resident #44's plan of care for bowel management. Refer to F690.",2020-09-01
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, frequency, and/or route for the MOM, [MEDICATION NAME], and [MEDICATION NAME]. 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 - 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. November 2017 - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December 2017 - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January 2018 - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February 2018 - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March 2018 - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Medical record review of a nurse's Progress Note dated 10/22/17 by Licensed Practical Nurse (LPN) #4 revealed .patient has noted BM but unable to pass due to impaction. Patient states it is hurting me get it out. Nurse at this time does impaction removal noted very dry hard stool. Medical record review of a nurse's Progress Note dated 2/22/18 by LPN #1 revealed .Resident refused all AM meds (medications) x (times) 3 attempts. Kicking, punching, and cursing at staff for no apparent reason. Impaction removed at approximately 1 PM. Blood noted in stool related to anal tearing from stool being so large and hard. Interview with LPN #1 on 3/7/18 at 11:00 AM, in the unit one medication storage room, confirmed she had manually removed a very large hard stool from Resident #44 on 2/22/18. Continued interview confirmed the resident had a small tear to the rectum due to the size of the bowel movement. Further interview revealed the Certified Nurse Assistants (CNAs) had informed her it was normal for Resident #44 to have hard stool requiring staff assistance for removal. Further interview revealed LPN #1 had no knowledge of a facility bowel protocol or any standing orders to treat constipation. Interview with CNA #1 on 3/7/18 at 11:14 AM, at the unit 1 nurse's station, revealed she was one of the regular care givers for Resident #44. Further interview confirmed Resident #44 did have constipation and required manual assistance from staff to remove the stool. Interview with Registered Nurse (RN) #1, Unit 1 Manager, on 3/7/18 at 12:19 PM, at the unit 1 nurse's station, revealed the nurse was not aware of any standing orders from Resident #44's Physician for constipation, but there was a facility bowel protocol the nurses followed. Further interview revealed the protocol was if no BM in 2 days a stool softener would be administered, if no BM in 3 days a laxative would be administered, if no results, an enema would be administered, and if no results from the enema the Physician would be notified for further orders. Interview with RN #2, Unit 2 Manager, on 3/7/18 at 12:25 PM, at the unit 1 nurse's station, revealed the nurse stated the facility currently had no bowel management protocol. Interview with Resident #44's Physician by phone on 3/7/18 at 1:50 PM, revealed he had standing orders in place to address constipation. Further interview confirmed he had a standing order of laxative of choice which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Medical record review of Resident #44's Physician orders [REDACTED]. Interview with Resident #44's Physician on 3/7/18 at 3:00 PM, in the conference room, revealed after 7 consecutive days without a BM, Resident #44 would require a laxative. Continued interview confirmed Resident #44 had no order to administer a laxative after 7 days without a BM. Further interview confirmed Resident #44 had the potential for pain and discomfort from constipation. Interview with LPN #3 by phone on 3/7/18 at 6:15 PM, confirmed the LPN had to manually remove stool from Resident #44's rectum. Continued interview confirmed she had no knowledge of physician standing orders to address constipation. Further interview confirmed if a resident had not had a BM in 2 days, night shift would administer MOM or [MEDICATION NAME]; if no results, day shift would administer an enema, and if no results the Physician would be notified. Continued interview confirmed the LPN was not aware of a facility bowel protocol. Interview with RN #3, Night Shift Supervisor, on 3/7/18 at 6:37 PM, at the unit 1 nurse's station, revealed the facility followed the bowel program sheet for the bowel protocol. Continued interview revealed if a resident had not had a BM in 3 days a suppository would be administered, if no results from the suppository, an enema would be administered, if no results from the enema, MOM would be administered. Further interview revealed the bowel program sheet was not clear on when to administer medications or what dosage was to be administered. Interview with LPN #4 on 3/8/18 at 8:34 AM, in the conference room, confirmed on 10/21/17, Resident #44 had hard visible stool in her rectum and was unable to push the stool out without the nurse's assistance. Further interview confirmed LPN #4 was not aware of a facility bowel protocol. Interview with RN #1 on 3/8/18 at 9:23 AM, in the conference room, revealed the facility's bowel protocol sheet did not have administration instructions to include dosage, frequency, and route. Further interview revealed there were no standing orders on the resident charts for nurses to review. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed nursing staff were to follow the facility's bowel protocol. Continued interview confirmed the nursing staff had not followed the facility's bowel protocol.",2020-09-01
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
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 intermittent catheterization for Resident #25. She stated the event happened in (MONTH) (YEAR). Continued interview revealed she stated the former DON had told RN #4 that she had obtained an order for [REDACTED].#25 gave consent for the former DON to perform the catheterization. Interview with Licensed Practical Nurse (LPN) #2 on 1/14/19 at 4:06 PM at the South hall nurse station revealed she was asked by the former DON to assist in placing an intermittent catheter for Resident #25. She stated this happened sometime in (MONTH) (YEAR). She stated there were 5 people including the former DON in the room with the resident. Continued interview revealed Resident #25 gave the former DON permission to place the catheter. She stated I didn't know there wasn't an order for [REDACTED]. Interview with the Administrator and Director of Nursing on 1/15/19 at 2:43 PM in the Administrator's office confirmed an order was not obtained for the former DON to catheterize Resident #25. Continued interview revealed the former DON was suspended, terminated, and reported to the Tennessee Board of Nursing.",2020-09-01
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 1/15/19 at 10:30 AM by the South nursing station revealed the LPN had provided care since the day after Resident #108 was admitted . The LPN stated the resident had been on oxygen since the LPN had been providing the resident care. The LPN confirmed the medical record did not have an order for [REDACTED].>",2020-09-01
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
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 (named Resident #22) presented with maggots in the plaques and fissures on his right thigh until a week after the finding. Refer to F600.",2020-09-01
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 #3 went to Resident #22's room to give the resident a bed bath. The CNA was asked by Resident #22 to perform a light wash (not too vigorous cleansing) due to increased pain in his hip. As CNA #3 began to wash the right hip with a wash cloth and soapy water, maggots were noted coming from the right thigh area crawling on the resident's abdominal folds. Continued interview with CNA #3 revealed he stopped cleaning the area and notified Licensed Practical Nurse (LPN) (Wound Care Nurse) #1 and the Administrator. He asked CNA #2 to help him. Both CNA #2 and CNA #3 returned to the room and he removed the covers to show CNA #2 the maggots. LPN #1 left the room and returned with a brown bottle of Dakin's (A dilute hypochlorite (bleach) antibiotic solution that kills the micro-organisms, but also harms healthy cells in all concentrations) and a toothbrush to cleanse the wound and skin folds and to remove the maggots. Further interview with CNA #3 revealed LPN #1 told both CNA #2 and CNA #3 to pour the Dakin's solution on the plaques and fissures to clean the area with the solution and the toothbrush. Further interview with CNA #3 revealed the maggots looked medium to large. Continued interview with CNA #3 revealed Resident #22 could feel the maggots crawling once they came out of the wound. CNA #3 stated Resident #22 said, .I feel them, I feel them . Review of the facility self-reported incidents confirmed the facility did not report this incident of neglect to the State Survey Agency. Refer to F600.",2020-09-01
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. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was placed on hospice on 6/17/19 and there was no Significant Change MDS completed for Resident #21. Interview with the Administrator on 8/6/19 at 3:25 PM in the West dining room revealed there was no Significant Change MDS when the resident was placed on hospice. Continued interview with the Administrator confirmed she (MDS Coordinator) failed to address it (significant change).",2020-09-01
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
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) on 8/22/19 at 11:14 AM in the Administrator's office confirmed .we should have oxygen tubing and the humidifier canister dated. Continued interview with the Interim DON confirmed .they (humidifier canisters) should be changed out when no water is in them .",2020-09-01
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 the CNAs the solution to pour on the plaques and fissures Continued interview with Resident #22 revealed .maggots would come out and then they would clean them off . Interview with CNA #2 on 8/7/19 at 2:42 PM in the West dining room revealed, .Licensed Practical Nurse (LPN) #1 stepped out to get Dakin's (A dilute hypochlorite (bleach) solution that shows effectiveness against Gram-Positive bacteria such as strep and staph, as well as a broad spectrum of anaerobic organisms and fungi) solution. Upon return to the room LPN #1 started pouring the Dakin's solution on Resident #22's plaques and fissures on his right thigh, then CNA #2 stated, .I poured some . Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed LPN #1 left the room, returned with a brown bottle of Dakin's and a toothbrush to start cleaning the plaques and fissures on his thigh and abdominal skin folds and to clear the maggots off. Further interview with CNA #3 revealed LPN #1 (Wound Care Nurse) told both CNA #2 and CNA #3 to pour the Dakin's on the plaques and fissures and to clean the area with the solution and the toothbrush. Telephone interview with the Former Nurse Practitioner (NP) on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (named Resident #22) presented with maggots in the plaques and fissures on his right thigh, and did not give any orders for Dakin's solution to be used. Telephone interview with the Pharmacy Consultant on 8/21/19 at 8:28 AM revealed Dakins solution was diluted bleach used to cleanse wounds. Continued interview with the Pharmacy Consultant confirmed nurses can use it (Dakins solution) as long there is an order .",2020-09-01
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 every shift the nurse should check the location; make sure it (PICC dressing) is timed and dated; assess for signs and symptoms of infection; and document. Continued interview with the NP when asked to look at the dressing confirmed she had .no idea when it was placed or when the dressing was changed . Interview with the ADON (Assistant Director of Nursing) on 8/7/19 at 2:30 PM in the West dining room confirmed .I should have marked it with a marker. I just marked it (PICC line transparent dressing) with a pen . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #32 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #32 required IV medications while a resident in the facility. Medical record review of the Physician Order Report dated 8/1/19 to 8/7/19 revealed an order to .Change PICC Line dressing PRN soiling or dislodgement. Special Instructions: Date and Time dressing for change and readjust standing PICC dressing schedule change . Observation on 8/5/19 at 10:51 AM in Resident #32's room revealed the PICC line dressing was dated 7/25/19. The dressing had been reinforced with tape. Observation and interview on 8/5/19 at 11:20 AM in Resident #32's room with the ADON confirmed the PICC dressing was noted with a date of 7/25/19. Continued interview with the ADON when asked what the facility policy was regarding PICC line dressing changes she confirmed .they are changed once a week .",2020-09-01
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,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 review revealed the resident was discharged from the facility on 8/6/16. Medical record review of the admission MDS dated [DATE] revealed the resident scored a 14 on the BIMS indicating the resident was independent with daily decision making and the resident was always continent of bladder. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS indicating the resident was independent with daily decision making and the resident was frequently incontinent of bladder. Medical record review of an admission Urinary Continence Evaluation dated 4/27/16 revealed the resident was continent of urine at the time of admission. Medical record review revealed no documentation a Urinary Continence Evaluation had been completed after 4/27/16. Interview with the DON on 10/18/16 at 8:10 AM, in the DON's office confirmed the resident had not been reassessed for a bladder retraining program after the decline in urinary continence was noted.",2020-09-01
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,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,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,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 and consult Registered Dietician if indicated. 9/22/17 Continue to encourage resident to be weighed. Continued review of the care plan revealed no further interventions were added after 9/22/17. Continued review revealed the care plan was not revised to include the resident's preferences of ice cream, chocolate milk, health shakes or the recommendations by the Dietician to offer fortified grits and provided additional fluids between meals. Interview with the Registered Dietician with the Corporate Dietician present on 12/13/17 at 9:15 AM in the conference room confirmed the comprehensive care plan was not revised to reflect the residents preferences and current interventions to prevent weight loss to Resident #47.",2020-09-01
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 Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #65 had received antipsychotic medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Further review of a Physician order [REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #65 received the medication as prescribed. Further review revealed no behavior monitoring for [MEDICATION NAME] or [MEDICATION NAME]. Interview with the Director of Nursing on 12/13/17 at 10:00 AM in the conference room confirmed the facility failed to complete behavior monitoring for Resident #39 who was administered antianxiety medication and Resident #65 who was administered an antipsychotic medication.",2020-09-01
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
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,"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
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,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,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
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
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 office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to follow the care plan for the use of bed bolsters for Resident #18. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident needed extensive assist of 2 staff members for bed mobility, transfer, toileting and had limited range of motion to all extremities. Medical record review of the Physician's Orders revealed .Self release lap belt in electric w/c (wheel chair) per resident request .4/10/19 . Medical record review of the care plan revealed no documentation of the use of a self release lap belt. Observation of Resident #33 on 6/3/19 at 3:19 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Observation of Resident #33 on 6/4/19 at 1:41 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Interview with the MDS Coordinator on 6/4/19 at 3:44 PM, in the MDS office, confirmed the lap belt had been in use since 4/10/19. Further interview confirmed the use of the self release belt had not been addressed on the resident's care plan. Interview with the ED on 6/5/19 at 7:35 AM, in the conference room, confirmed the facility failed to develop a care plan for Resident #33's use of a self release lap belt.",2020-09-01
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 Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to implement care planned intervention to prevent accidents for Resident #18.",2020-09-01
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,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,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,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,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,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. Continued interview confirmed the facility failed to complete a skin assessment in a timely manner for Resident #29. Interview with the Wound Nurse on 6/12/18 at 1:40 PM, in the MDS office revealed the resident had a scheduled skin assessment to be completed every Friday. Continued interview confirmed the residents skin assessment was refused by the resident on 6/8/18 and not completed until 6/11/18 and a deep tissue injury was noted at that time. Further interview confirmed the facility failed to complete a skin assessment in a timely manner resulting in the development of a deep tissue injury. Observation of the resident's pressure ulcer with the Wound Nurse on 6/13/18 at 9:10 AM, in the resident's room revealed a dry deep tissue injury, approximately quarter size, purple in color to the right heel.",2020-09-01
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
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 or since earlier today. There was no documented pain assessment conducted prior to or after the administration of the Biofreeze. Interview with RN #4 on 8/10/17 at 11:35 AM in the East Hall nurses station, RN #4 was asked about pain assessments and topical medications for pain. RN #4 stated, .a pain level is done at anytime there is a complaint of pain .prn (as needed) topical there is a pain assessment before .reassessed after the medication . 3. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #190 had a Brief Iinterview for Mental Status (BIMS) score of 13, indicating normal cognition, and received pain medication as needed. Review of the 14 day MDS dated [DATE] revealed Resident #190 had a BIMS of 13 and received non-pharmacological interventions for pain. A physician's orders [REDACTED].[MEDICATION NAME] .50 MG (milligram) TABLET .ONE .BY MOUTH EVERY 6 HOUR AS NEEDED FOR INCREASED PAIN . Observations on the East Hall on 8/10/17 at 7:20 AM, revealed Certified Nursing Assistant (CNA) #1 came to the East Hall nurse's station and reported to Licensed Practical Nurse (LPN) #4 that (Resident #190) is hurting and wants a pain pill. LPN #4 completed the controlled medication count with RN #2 and administered medications to another resident without addressing Resident #190's pain. While LPN #4 was administering medications to another resident, the surveyor went to Resident #190's room and the resident was lying in bed grimacing. Resident #190 was asked if he was hurting and he grabbed his right side and moaned, My right side hurts bad Resident #190 was asked how long he had been hurting and he stated, About an hour, I told them I needed something. Resident #190 was asked if he could rate his pain on a scale between 1 and 10, with 10 being the worst and he stated, 7. At 7:56 AM, LPN #4 entered Resident #190's room to obtain his vital signs. As she placed the blood pressure cuff on Resident #190's left arm, Resident #190 stated, I'm hurting. LPN #4 returned to her cart and did not perform a pain assessment at that time. Upon return to Resident #190's room LPN #4 asked him to rate his pain on the pain scale. Still grimacing, Resident #190 stated, 7. At 8:06 AM, LPN #4 administered Resident #190's pain medication with his morning medications. Resident #190's pain was reported to LPN #4 at 7:20 AM and he received his pain medication at 8:06 AM, 46 minutes after LPN #4 was made aware the resident was in pain. Interview with LPN #2 on 8/10/17 at 1:46 PM, on the East Hall near room [ROOM NUMBER], LPN #2 was asked how long a resident should wait to get pain medication after the resident reported the need for medication and LPN #2 stated, They should get it right away . Interview with the Director of Nursing (DON) on 8/11/17 at 5:08 PM, in the Conference Room, the DON was asked when a resident should receive pain medication after reporting pain and the DON stated, as soon as possible. 4. Review of the facility's [MEDICAL TREATMENT] ASS[NAME]IATES .NURSING HOME AGREEMENT dated (MONTH) 5, 1998, revealed that the agreement did not address the 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. Interview with the DON on 8/10/17 at 9:25 AM, in the Assistant Director of Nursing/Dietary Office, the DON was asked if the [MEDICAL TREATMENT] Agreement addressed the development and implementation of the resident's [MEDICAL TREATMENT] care plan. The DON read over the agreement and stated, I don't see it specifically in here. The DON was asked if the [MEDICAL TREATMENT] Agreement addressed the interchange of information necessary for the care of the [MEDICAL TREATMENT] resident. The DON stated, Not specific, no.",2020-09-01
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 .Time Frames .Initiated promptly on admission/readmission/or return .2. Tools .Braden .Assessment .Admission Nursing Assessment .Medication list, Skin Assessment Record .d. Wound Assessment Record .Wound assessment includes type, stage, locations and measurement of site .(length, width and depth) .Exudate .type, odor, amount, color .wound bed to include .necrotic tissue .slough .fribin ([MEDICATION NAME]), granulation, epithelization, tunneling/undermining .Periwound & (and) wound edge appearance to include description and measurement .signs/symptoms of infection . 4. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented that Resident #37 had severely impaired cognition, was at risk for developing pressure ulcers, and had a stage 4 pressure ulcer with measurements 13.0 centimeters (cm) long, 15.0 cm wide and 6.0 cm deep. Review of an Admission Nursing Assessment Report dated 7/14/17 revealed a body diagram for Resident #37 that had the coccyx/sacral area marked stage IV (4) sacrum and the upper thigh/buttock area marked unstageable, and a nursing note that documented, .Decubitus ulcers noted to sacrum and R (right) thigh w/ (with) wound care as ordered. There were no other wound assessments performed for the stage IV coccyx/sacral wound or for the unstageable upper thigh/buttock wound on the Admission Nursing Assessment Report. Review of the Admission Nursing Assessment signed by an Registered Nurse (RN) on 7/15/17 documented .decubitis ulcer noted to sacrum and R (right) thigh w(with)/wound care as ordered There was no documentation that wound care orders were received on admission. A Braden Scale Report for Resident #37 was not performed until 7/16/17, with a score of 11 obtained which indicated a high risk for developing a pressure ulcer. There was no initial wound assessment completed on 7/14/17 and no assessments of the sacral/coccyx or ischial wounds on 7/15/17 or 7/16/17. The WEEKLY WOUND ASSESSMENT PROGRESS NOTES dated 7/18/17 documented, .readmitted to facility from (named hospital) (with) extensive wounds .Stg. (stage) 4 p/u (pressure ulcer) to sacral/coccyx .fascia, muscle, and sub q (subcutaneous) tissue (with) some bone exposure . Review of the physician's orders [REDACTED]. Review of the Medication, Treatment and Task Administration Record Report for (MONTH) revealed that wound treatments were not provided for the sacral/coccyx or right ischial wounds until 7/17/17. Observations in Resident #37's room on 8/9/17 at 2:13 PM, with Registered Nurse (RN) #1, revealed Resident #37 had a large, deep wound of the sacrum. RN #1 assessed the wounds with measurements of the sacral wound of 9.0 by (x)15.0 x 5.0 cm (length by width by depth in centimeters) and a large wound on the upper thigh/buttock region (ischium) with measurements obtained by RN #1 of 5.5 x 5.5 x 2.4 cm. Interview with Licensed Practical Nurse (LPN) #2 on 8/10/17 at 1:16 PM, at the East Hall nurse's station, LPN #2 was asked what was the procedure when a resident with pressure wounds was admitted to the facility after 5 PM on a Friday. LPN #2 stated, We have a check off list and we have so much we can do prior to them getting here if we have the transfer orders .we get them verified, we fax the orders from the transferring facility to Medical Doctor (MD) #1. She looks over the orders, adds to them, okays them, signs them and sends them back .they normally send wound orders with them from the hospital or we contact Registered Nurse (RN) #1 or Medical Doctor (MD) #1 or MD #2 .take their vitals (vital signs), do a head to toe assessment .look at their skin within an hour of them getting here .if there are dressings remove and see what's underneath .cover it with a clean dressing until we get orders (for wound care). We call RN #1, the wound care nurse, and she contacts MD #2 .calls us back with them, those treatment orders. I would do the treatment at that time. LPN #2 was asked if she obtained measurements or described the wound bed when she assessed a wound on admission. LPN #2 stated, No .the Braden scale is done with those admission forms. Interview with LPN #3 on 8/10/17 at 2:13 PM, at the East Hall nurses station, LPN #3 was asked if a wound assessment was performed on admission for Resident #37 and if the resident received wound care for the sacral and ischial wounds on 7/14, 7/15, or 7/16/17. LPN #3 confirmed that a wound assessment was not performed on the sacral and ischial wound and that an order had not been obtained for wound care. LPN #3 confirmed wound care treatments had not been provided for the sacral and ischial wounds from 7/14 to 7/17/17. LPN #3 was asked if wound assessments were done when residents with wounds were admitted on the weekends. LPN #3 stated The resident is assessed when the wound care nurse returns on Monday. LPN #3 confirmed that a wound assessment was not performed by the nursing staff on the admission of Resident #37. Telephone interview with MD #2 on 8/10/17 at 4:30 PM, MD #2 was asked if he expected the nurses to call him for orders when a resident is admitted with pressure wounds after 5 PM on Friday or on the weekend. MD #2 stated, Yes. MD #2 further stated .there is a delay in what I want started . Interview with RN #1 on 8/10/17 at 5:34 PM, in the Conference Room, RN #1 was asked to explain the procedure when admitting a resident after 5PM on Fridays or on weekends. RN #1 was asked, if it was important to get orders for the weekend. RN #1 stated, .Definitely Saturday or Sunday, she should have gotten treatment . Interview with the Director of Nursing (DON) on 8/11/17 at 5:08 PM, in the Conference Room, the DON was asked if it was appropriate for a resident with stage 4 pressure ulcer to not receive wound care on the weekend. The ADON stated, .they would need wound care, yes, Ma'am.",2020-09-01
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 stored in his room. LPN # 6 stated, I'll have to take a look at his chart . 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 is acceptable for residents with dementia to have razors in their bathroom. The DON stated, .No it is not .",2020-09-01
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,"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,"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
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,"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) Report documented, .[MEDICAL CONDITION]/[MEDICAL CONDITION] .AT BEDTIME PER PRESCRIBED .August 20 .A (Administered) .August 21 .A . 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 a [MEDICAL CONDITION]/[MEDICAL CONDITION] machine in the middle of the room on a table against the wall, with the tubing and mask unattached, and a gray plastic pipe and house shoes placed of top of the mask and tubing. Interview with Resident #27 on 8/23/18 at 10:20 AM, in Resident #27's room, Resident #27 was asked if he used his [MEDICAL CONDITION]/[MEDICAL CONDITION]. Resident #27 stated, No. I haven't used it in about 2 months. It is broken, see it is laying on that table over there and has been for a long time. Interview with the DON on 8/22/18 at 11:45 AM, in the conference room, the DON confirmed the TAR documented the [MEDICAL CONDITION]/[MEDICAL CONDITION] treatment was administered at bedtime 8/20/18 and 8/21/18. Interview with the DON on 8/22/18 at 12:20 PM, in Resident #27's room, the DON confirmed the [MEDICAL CONDITION]/CIPAP was broken. The DON stated, I don't know why this tray won't go in here .",2020-09-01
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,"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,"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,"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,"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,"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,"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
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 facility reported the incident to the state survey agency on 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware of the allegation). Telephone interview with the Administrator on 6/4/19 at 8:25 AM confirmed the facility failed to report the allegation until 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware) and the facility failed to follow facility policy.",2020-09-01
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 as wandering. Further interview confirmed the MDS was not accurate to reflect the resident's wandering behavior.",2020-09-01
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,"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 responsibility to develop, revise, and review the care plans and the facility failed to revise the care plans for Resident #100 falls and skin integrity to include the scalp laceration. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to update and revise the care plans on Falls and Skin Integrity for Resident #100 for the care and treatment of [REDACTED].",2020-09-01
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 hospital .Laceration c (with) 2 sutures to (r) (right) posterior scalp intact .only orders is to remove sutures in 10 days . Medical record review of the 11/2018 and 12/2018 Medication, Treatment and Task Administration Record Report (MAR/TAR) revealed no documentation or observations had been added for the treatment and care of the laceration and sutures to Resident #100's head. Observation of Resident #100 on 12/4/18 at 8:30 AM, in the resident's room, revealed 2 sutures intact to the right posterior side of the head. Interview with the Registered Nurse/Resident Care Coordinator (RN/RCC) #1 and RN #1 on 12/4/18 at 2:25 PM, in the Conference Room, confirmed RN #1 failed to add the laceration/suture care to the MAR/TAR for Resident #100. Interview with Certified Nursing Assistants (CNA) #2 and #3 on 12/4/18 at 2:45 PM, in the third floor lounge, confirmed they were assigned to care for Resident #100 and were not aware Resident #100 had sutures in her scalp. Interview with the Medical Director on 12/4/18 at 3:00 PM, in the 3rd floor chart room, confirmed the facility failed to follow the ER discharge orders for Resident #100. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to place the discharge instructions for the care and treatment of [REDACTED].#100 on the MAR/TAR. Further interview confirmed the facility failed to follow the ER discharge instructions for Resident #100 following a fall with laceration/sutures.",2020-09-01
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 11/28/18-12/1/18 the resident's oxygen saturation averaged 94% with no record of the amount of liters oxygen being delivered per minute when the oxygen level was measured. Medical record review of the Daily Skilled Nurses Note on 12/3/18 at 12:00 PM, revealed no recorded vital signs. Continued review of the one entry for 12/3/18 revealed, Resting in bed at this time. NC (nasal cannula) in place delivering O2. Pt had SOB (shortness of breath) this am (morning) and didn't have NC in. NC placed and O2 sat 91% shortly thereafter. Call light in reach. Will monitor . Medical record review of the Nurse Practitioner's progress noted dated 12/4/18 revealed, Pt seen today for reports of SOB. Pt treated for [REDACTED]. Despite diuretics, her SOB has not improved. O2 demand has increased (need for increased liters of supplemental oxygen) and pt feels as if she cannot get enough air in. Pt does report unilateral LLE (lower leg [MEDICAL CONDITION] in both legs) since admission O2 sat (saturation) 90% on 5 Lpm (5 liters per minute of oxygen by nasal cannula) .1) SOB - obtain .CXR. Give [MEDICATION NAME] 40 mg IM (intramuscular) 1 dose now .2) Acute hypoxemic (low oxygen level) resp (respiratory) failure - now on 5 Lpm (5 liters per minute). Pt's O2 sat during exam was 89-91%. Pt did not require O2 prior to hospitalization . With [MEDICAL CONDITION] will attempt to keep sat >90%. Avoid high O2 flow (amount of oxygen administered per minute) d/t (due to) unknown hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream) hx (history) . Medical record review of the Daily Skilled Nurses Notes from 11/26/18-12/4/18 revealed no record of the resident being assisted to splint and cough. Medical record review of the Baseline Care Plan, undated and unsigned, revealed Care Area .Respiratory .Oxygen 1.5 L (liters per minute) keep sats (oxygen saturation) 90%-92%. Continued review revealed no intervention listed related to the aggressive [MEDICAL CONDITION] toilet prescribed by the Nurse Practitioner (NP) to assist the resident to splint and cough. Observation and interview with the resident on 12/3/18 at 9:00 AM, in her room, revealed she was seated on her bed, appeared short of breath and this increased when she attempted to answer more than a few questions. Observation and interview with the resident on 12/5/18 at 2:00 PM, in her room, revealed she was seated on her bed with unlabored respirations. Interview continued and the resident stated she was .better .up all night off and on going to the bathroom (the same night after receiving the 40 mg of [MEDICATION NAME] IM). Interview with the resident's Licensed Practical Nurse (LPN) #2 on 12/3/18, at 3:00 PM, in the conference room, revealed the LPN restated the information provided on his nursing entry for 12/03/18. In addition, he added the resident had been in the low 80's (referring to oxygen saturation) when she returned from the bathroom without her oxygen). Continued interview confirmed he had not notified the Nurse Practitioner who was onsite of the low oxygen saturation and had not assessed the resident's lung sounds. Interview with the Resident Care Coordinator (RCC) #1 on 12/4/18 at 9:05 AM, at the third floor nursing station, revealed the resident was not weighed on Monday 12/3/18 and stated LPN #2 told the RCC, .She should have been. Interview continued and revealed the NP had not seen the resident on Monday 12/3/18. Further interview confirmed a NP had not seen the resident for the previous 6 days and the resident had not been weighed since 11/30/18. Interview with the NP on 12/4/18 at 8:45 AM, in the third floor nursing station, revealed I have never seen the resident (#105) .plan to assess her this morning . Interview with RCC #2 on 12/4/18 at 1:15 PM, in the conference room, revealed the resident's weight this day was 153 pounds and confirmed this was an increase of 5 pounds from the last weight of 148 pounds, 4 days earlier. Further interview confirmed the weight was to be done every Monday and had not been done as ordered. Continued interview revealed the chest x-ray had been reported and included in the findings The lungs again demonstrate patchy infiltrate in the right base, probably with effusion (fluid)). There is an active process in the left base . Interview with the Director of Nurses (DON) on 12/4/18 at 1:45 PM, in the conference room, revealed the nurses were to take SaO2 (oxygen saturation level in the bloodstream) on all residents as part of the routine vital signs. Continued interview revealed the DON could not provide a formal respiratory care policy. A document titled O2 Saturation Guidelines, undated, was provided for the interview. Further interview confirmed the 3 guidelines provided did not require the information of the amount of oxygen being delivered when oxygen saturation was obtained. Continued interview revealed .a lot of problems with residents' oxygen levels are found by the rehab staff . Further interview revealed Resident #105 had not been fully assessed daily by the nursing staff for her respiratory status and had not been care planned to receive the Aggressive [MEDICAL CONDITION] toilet prescribed by the NP on 11/26/18.",2020-09-01
201,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2019-12-18,656,D,0,1,C5Z011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the care plan for falls for 1 resident (#86) of 23 sampled residents. The findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of the Comprehensive Care Plan, dated 12/3/19 revealed .Keep bed in lowest position . Medical record review of the Certified Nursing Assistant Care Plan, dated 12/3/19, revealed to keep Resident #86's bed in lowest position. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed, without injury, on 12/12/19 at 6:20 PM. Continued review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM, in the conference room, confirmed the resident was not in the low position bed on 12/12/19. Interview with the Director of Nursing on 12/18/19 at 9:54 AM, in the conference room, confirmed the care planned low bed intervention was not in place at the time of the fall.",2020-09-01
202,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2019-12-18,689,D,0,1,C5Z011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, observation and interview the facility failed to add a new intervention after a fall for 1 resident (#69) and failed to implement a care plan intervention to prevent accidents for 1 resident (#86) of 5 residents reviewed for accidents. The findings include: Review of the facility policy, Falls Policy, revised 7/14/17 revealed .Based on the preceding assessment, the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falls .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falls, until falling reduces or stops or until a reason is identified for its continuation . Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #69's care plan revised 3/5/19 revealed .Bed Alarm, ensure functioning and placement qshift (every shift) . Continued review revealed no new interventions had been implemented after the 9/20/19 fall. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment and required extensive assistance of 1 for bed mobility, transfers, toileting, and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #69 scored a 19. Continued review revealed a resident score greater that 13 indicated a high risk for falls. Review of an Event Report facility dated 9/20/19 revealed Resident #69 had an unwitnessed fall in the resident's room on 9/20/19 without injury. Continued review revealed the immediate measures implemented was a bed alarm (implemented on 3/5/19). Observation on 12/18/19 at 8:30 AM, in the resident's room, revealed Resident #69 sleep in bed with a bed alarm in place, a fall mat to the left side of the bed, and the call light within reach. Interview with the Director of Nursing (DON) on 12/18/19 at 2:00 PM, in the DON's office, confirmed the facility failed to implement a new falls intervention after the fall on 9/20/19 and failed to follow the facility policy for falls. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission MDS dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of Resident #86's Fall Risk Assessment Tool dated 11/26/19 revealed the resident was a high fall risk. Medical record review of the Certified Nursing Assistant Care Plan dated 12/3/19, revealed .Keep bed in lowest position . Medical record review of the Comprehensive Care Plan dated 12/3/19 revealed Resident #86 had a history of [REDACTED]. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed without injury on 12/12/19 at 6:20 PM. Further review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION .Patient fell to floor from bed trying to roll herself off a bedpan . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM , in the conference room, confirmed the resident's bed .was not in the low position as I would have expected for a resident here for falls and [MEDICAL CONDITION] . Interview with the DON on 12/18/19 at 9:54 AM, in the conference room, confirmed the low bed intervention was not in place. In summary, the facility failed to ensure the low bed intervention was in place to prevent a fall for Resident #86 on 12/12/19.",2020-09-01
204,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2019-11-20,791,D,0,1,ZZRT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#11) received routine dental services of 18 residents sampled. The findings include: Review of the facility's policy Dental Services, undated, revealed .To ensure patients are receiving the care and services necessary for proper denture and dental health .Build accountability into each process to ensure effectiveness .Establish process for communication of dental needs .of patients .Ensure all partners are aware of process for communication of dental needs . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the care plan dated 9/3/19 revealed .risk of altered nutrition status .Dental consult as warranted . Medical record review of a Food and Nutrition Services progress note dated 9/10/19 revealed .Staff contacted RD (Registered Dietician) to notify of (Resident #11's name) reporting she is having trouble with her dentures and needs new ones. She reports that she is getting choked on her food because she can't chew it. Diet change to Low Sodium, Mechanical with ground meats for ease of chewing. Reassess diet texture change as needed/when new dentures are obtained . Medical record review of a physician's orders [REDACTED]. Interview with Resident #11 on 11/18/19 at 2:47 PM, in the resident's room, revealed her dentures no longer fit and she wanted new dentures. Further interview revealed she had reported the issue to the facility but had not been seen by the dentist. Interview with the Social Services Assistant on 11/19/19 at 12:34 PM, in the social services office, revealed the nursing staff maintained the list of residents to be seen by the dentist. Interview with the Resident Care Coordinator (RCC) on 11/19/19 at 12:46 PM, in the RCC's office, revealed the nursing staff did not maintain the list of residents to be seen by the dentist and the RCC was not aware of which residents were on the list. Interview with the Administrator on 11/19/19 at 12:49 PM, in the Administrator's office, revealed he maintained the list of residents to be seen by the dentist. Continued interview confirmed he had not been made aware of the resident's need to be seen by the dentist and Resident #11 had not been added to the dental list. Further interview confirmed it was his expectation to be notified immediately of dental concerns so the resident can be added to the dental list to be seen at the next visit or sooner if needed. Interview with the Director of Nursing (DON) on 11/19/19 at 12:53 PM, in the Administrator's office, confirmed she was unaware Resident #11 had a need to see the dentist. Continued interview confirmed it was her expectation for the RD or the staff member who informed the RD of Resident #11's need to be seen by the dentist to have notified the Administrator or DON.",2020-09-01
205,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-06-28,225,D,1,0,2N5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the state agency timely for 1 resident (#3) of 2 residents reviewed for abuse. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed an allegation of abuse was reported by Certified Nursing Assistant (CNA #1) on 5/31/17 at 2:30 PM. Continued review revealed the CNA reported the abuse to the Charge Nurse who reported to the Director of Nursing and Social services. Interview with the Administrator confirmed the facility failed to report the allegation of abuse to the State Agency until (MONTH) 1, (YEAR) at 10:30 AM. Continued interview confirmed the facility failed to report the abuse within two hours as required.",2020-09-01
207,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-12-13,609,D,0,1,D4AU11,"**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 and report timely an allegation of abuse for 1 of 1 (Resident #109) sampled residents. The findings include: Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy documented, .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #109 was admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 9/3/17 documented, .pt (patient) upset this afternoon stating that two men came into her room and was beating her and whipping her with many items. Stated that they hit her so hard they made her pee herself and they almost threw her off the bed. Pt stated they looked mexican . Interview with the Director of Nursing (DON) on 12/11/17 at 2:27 PM, in the conference room, the DON stated, .I wasn't aware that nursing note was in the record . The DON was asked if there had been an investigation. The DON stated, No. The DON was asked what was facility policy regarding allegations of abuse. The DON stated, .report it immediately .I spoke with the nurse and the nurse said she didn't think of it as abuse but screened her for hallucinations since she has had hallucinations in the past . Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 9:04 AM, in the conference room, LPN #1 was asked why she did not report Resident's 9/3/17 allegation of abuse. LPN #1 stated, .It's my bad .she has hallucinations at times .I was trying to document her behaviors .I should have reported it to the DON . Interview with the Administrator on 12/13/17 at 9:15 AM, in the DON's office, the Administrator was asked what he expected his staff to do when there are allegations of abuse. The Administrator stated, .report it to us (administration) immediately .",2020-09-01
208,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-12-13,880,D,0,1,D4AU11,"**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 when 2 of 3 (Licensed Practical Nurse (LPN) #2 and 3) nurses failed to perform hand hygiene during medication administration. 1. The facility's INFECTION CONTROL MANUAL .HANDWASHING procedure documented, Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . 2. Observations on the 300 hall on 12/12/17 at 11:00 AM, revealed LPN #2 removed a bottle of Aspirin from the cart, donned gloves, placed an Aspirin in a plastic medication cup, removed her gloves, finished preparing medications, entered room [ROOM NUMBER]A, donned gloves, administered nasal spray and medications, removed gloves, walked out to the medication cart, donned gloves, cleaned the nozzle on the nasal spray bottle, removed gloves, and signed out the medications. LPN #2 failed to perform hand hygiene between glove changes during medication administration. 3. Observations on the 200 hall on 12/12/17 at 12:01 PM, revealed LPN #3 donned gloves, mixed an intravenous (IV) medication, cleaned a glucometer with a bleach wipe, removed her gloves, set up oral medications, donned gloves, obtained supplies and set up the glucometer, removed her gloves, entered room [ROOM NUMBER]A, donned gloves, connected the IV to the pump, picked up the call light and bed control off the floor, removed her gloves, donned new gloves, administered oral medications, performed a finger stick, removed her gloves, donned new gloves, connected the IV to the resident and started the pump, exited the room, disposed of the lancet, cleaned the glucometer, removed her gloves, and signed out the medications. LPN #3 failed to perform hand hygiene between glove changes during medication administration. 4. Interview with the Director of Nursing (DON) on 12/13/17 at 11:25 AM, in the DON's office, the DON was asked what she expected her staff to do between glove changes. The DON stated, Wash their hands.",2020-09-01
209,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,636,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely annual Minimum Data Set (MDS) assessment for 1 resident (Resident #3) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Annual assessment .must be completed on an annual basis .AND within 92 days since the .previous .Quarterly . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #3 had a Quarterly MDS completed on 8/14/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #3's next annual MDS should have been completed on 11/14/2019. The resident's Annual MDS had not been completely timely (76 days overdue).",2020-09-01
210,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,638,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely quarterly Minimum Data Set (MDS) assessment for 1 resident (Resident #4) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Quarterly assessment .must be completed at least every 92 days following the previous .assessment of any type . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #4 had a quarterly MDS completed on 8/23/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #4's next quarterly MDS should have been completed on 11/23/2019. The resident's Quarterly MDS had not been completely timely (67 days overdue).",2020-09-01
211,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,658,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure adequate supply of medications were available for 1 resident (Resident #131) of 8 residents reviewed for medication administration, resulting in staff borrowing pain medication from Resident #11 to administer to Resident #131. The findings include: Review of the facility policy titled, Acquisition of Medications for Residents, undated, showed .Pharmacy will provide medications for the residents .Reorder requests can be made by writing the drug needed on the provided refill request form, pulling the refill sticker from the pharmacy label and placing it on the provided refill request form, or calling the pharmacy . Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #131's Physician Recapitulation Orders dated 1/1/2020-1/31/2020, revealed .[MEDICATION NAME] 5-325 (also called Hydro/APAP-used to treat pain) TABLET-Give one tablet by mouth twice a day . Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a controlled drug record for Resident #11 showed, .HYDRO/APAP .5-325MG (MILLIGRAM) .FOR PAIN . On 1/13/2020, Licensed Practical Nurse (LPN) #2 borrowed 1 pill from Resident #11's pain medications to administer to Resident #131. During an interview on 1/29/2020 at 10:50 AM, the facility Pharmacist stated a Pharmacist is on call 24 hours a day 7 days a week. The facility does not have an emergency box with pain medication. If a pain medication is needed the Pharmacist will come in and get the medication prepared. The staff will sometimes borrow from other residents if it is in the middle of the night. During an interview on 1/29/2020 at 1:10 PM, LPN #3 stated when a resident's pain medication is in the red zone (a colored area on the medication card indicating the medication needs to be re-filled) on the narcotic card, nursing staff are to pull the label sticker and re-order the medication. During a telephone interview on 1/29/2020 at 1:35 PM, LPN #2 stated if she borrowed a narcotic medication from a resident, it would be because there was none available for another resident; .that is the only reason I would borrow .If it is a weekend we can call the Pharmacist in an emergency, but if the medication is routine we usually borrow the medications from someone else . During an interview 1/29/2020 at 2:10 PM, the facility Pharmacist stated the pain medication had not been re-ordered for resident #131 until 1/14/2020. The process is for the nurse to pull the label from the medication card; there is an area in red that lets them know when it's time to re-order. During an interview on 1/29/2020 at 2:18 PM, the Director of Nursing stated it was her expectation for the nurses to order medications timely. The Director of Nursing confirmed the facility had not ordered medications timely for Resident #131.",2020-09-01
212,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,684,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide proper positioning while seated in a wheelchair for 1 resident (Resident #53) of 28 sampled residents. The findings include: Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 5/6/2019 revealed .Assist with all mobility needs prn (as needed) .Rehab to eval (evaluate) and treat as needed . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment and used a wheelchair for mobility. Observation of Resident #53 on 1/27/2020 at 11:08 AM, revealed the resident was propelling herself down the hallway in a wheelchair. The resident's feet were not touching the floor and there were no foot rests on the wheelchair. During an interview and observation of Resident #53 on 1/28/2020 at 2:00 PM, Licensed Practical Nurse (LPN) #5 confirmed Resident #53's feet were not touching the floor and there were not footrests on the wheelchair. LPN #5 stated therapy could be consulted for positioning when a wheelchair was not the correct height for a resident, but there was no documentation of a therapy consult for Resident #53. During an interview on 1/28/2020 at 2:14 PM, Certified Nursing Assistant (CNA) #1 stated Resident #53 sometimes used the tips of her toes to propel herself in the wheelchair. CNA #1 stated the resident's feet did not touch the floor when she was seated in the wheelchair. Observation of Resident #53 on 1/28/2020 at 4:38 PM, revealed the resident seated in a wheelchair in the hallway propelling herself using her arms. The resident's feet were not touching the floor and there were no foot rests on the wheelchair. During an interview on 1/29/2020 at 8:35 AM, the Assistant Director of Nursing (ADON) confirmed it was her expectation for the nursing staff to evaluate a resident who was not properly positioned in a wheelchair. The ADON stated a different wheelchair should be obtained or consulted therapy. During an interview on 1/29/2020 at 8:49 AM, the Rehabilitation Director stated Resident #53 had not been evaluated by the therapy department for wheelchair positioning.",2020-09-01
213,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,689,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of manufacturer guidelines, record review, observation, and interview, the facility failed to use a mechanical lift safety for 1 (Resident #20) of 142 residents screened for accidents during the initial pool, which resulted in Resident #20 being left in a mechanical lift unattended. The findings include: Review of the facility policy titled, Lift Free Policy, dated 11/8/1994, showed .Effective 11/9/1994 it will be facility policy for all employees in the Nursing Department to use the mechanical lifts for lifting those residents identified .as requiring the use of a lift .the policy is instituted for the safety of our .residents . Review of the manufacturer guidelines for use of the mechanical lift dated 1/2014, showed .Before Approaching the patient .ensure that the battery pack supplied is fully charged before use . Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 was severely cognitively impaired and required extensive assistance of one staff member for bed mobility and transfers. During observation in the resident's room on 1/27/2020 at 11:18 AM, Resident #20 was sitting on a pad in a mechanical lift, suspended above the wheelchair. CNA #2 was attempting to lower the resident using the lift to the wheelchair. Certified Nursing Assistant (CNA) #2 stated .it will not go on down the battery must be dead. I'll have to get another battery to use . CNA #2 exited the resident's room, leaving the resident unattended, and proceeded to walk up the hallway to the nurse's station. CNA #2 returned to the room with a different battery for the lift. The battery did not work. CNA #2 exited the room a second time and left the resident unattended to obtain another battery for the lift. She returned to the resident's room with the new battery. The second battery applied to the lift did work, and at 11:30 AM, 12 minutes later, Resident #20 was lowered to her wheelchair using the mechanical lift. During an interview on 1/27/2020 at 11:32 AM, CNA #2 stated, .I should not have left resident unattended in the room .because lift battery not working . During an interview on 1/29/2020 at 10:01 AM, the Director of Nursing stated it was her expectation for the staff not to leave a resident unattended while in a lift device. The facility did not ensure the safety of Resident #20.",2020-09-01
214,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,726,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and staff skills and competency reviews, the facility failed to provide skills competencies for 1 (CNA #2) of 4 Certified Nursing Assistants (CNA) reviewed, which resulted in CNA #2 using a mechanical lift incorrectly for Resident #20. The findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 was severely cognitively impaired and required extensive assistance of one staff member for bed mobility and transfers. Observation in the resident's room on 1/27/2020 at 11:18 AM, showed Resident #20 sitting on a pad in a mechanical lift suspended above the wheelchair. CNA #2 was attempting to lower the resident using the lift to the wheelchair. CNA #2 stated .it will not go on down. The battery must be dead .I'll have to get another battery to use . CNA #2 exited the resident's room, leaving the resident unattended, and proceeded to walk up the hallway to the nurse's station. CNA #2 returned to the room with a different battery for the lift. The battery did not work. CNA #2 exited the room a second time and left the resident unattended to obtain another battery for the lift. She returned to the resident's room with the new battery. The second battery applied to the lift did work, and at 11:30 AM, 12 minutes later, Resident #20 was lowered to her wheelchair using the mechanical lift. During an interview on 1/27/2020 at 11:32 AM, CNA #2 stated .I should not have left resident unattended in the room .because lift battery not working . Review of staff training and competencies titled, .CNA Skills Day Checklist . dated 7/2/2019, showed CNA #2 did not receive the skills competency for the year 2019. During an interview on 1/29/2020 at 3:00 PM, theAssistant Director of Nursing stated, .(CNA #2) was on vacation on 7/2/2019 and did not attend the annual CNA skills day .she did not receive the skills checklist and she did not complete the competency .the facility usually has a make-up day, but we did not have one for last year (2019) .",2020-09-01
215,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,759,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure the medication error rate was less than 5 percent. There were 32 opportunities with 3 errors resulting in a 9% medication error rate. The errors involved 2 of 8 residents (Residents #389 and #112) in the sample. The findings include: Resident #389 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician admission orders [REDACTED].TAKE 34 GRAMS DAILY .FOR CONSTIPATION .SERTRALIN ([MEDICATION NAME]) (also called [MEDICATION NAME] a medication used to treat depression) 100 MG (milligram), take 1 1/2 TAB PO (by mouth) DAILY FOR MOOD/DEPRESSION . During observation of the 200 hallway medication administration pass on 1/28/2020 at 8:05 AM, Licensed Practical Nurse (LPN) #1 prepared and administered the following medications to Resident #389: [MEDICATION NAME] 17 gm and [MEDICATION NAME] 50 mg. During an interview on 1/28/2020 at 9:08 AM, LPN #1 confirmed he administered [MEDICATION NAME] 17 gm, and the order was for 34 gm, and administered [MEDICATION NAME] 50 mg, and the order was for [MEDICATION NAME] 150 mg. During an interview on 1/29/2020 at 2:18 PM, the Director of Nursing (DON) confirmed the facility did not follow Physician orders [REDACTED].#389. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician Recapitulation Orders dated 1/1/2020-1/31/2020, showed .POTASSIUM CL (Chloride) ER (Extended Release) 20 MEQ (Milliequivalents) give one tablet by mouth daily .May Crush Medications .No . During observation of the 500 hallway medication administration pass on 1/28/2020 at 8:17 AM, LPN #4 crushed and administered Potassium Chloride ER 20 MEQ by mouth in apple sauce. During an interview on 1/28/2020 at 8:50 AM, LPN #4 confirmed she had crushed and administered Potassium Chloride ER 20 MEQ to Resident #112. During an interview on 1/28/2020 at 9:04 AM, the DON confirmed Potassium Chloride ER should not be crushed and the facility did not follow the physician's orders [REDACTED]. During an interview on 1/28/2020 at 2:55 PM, the Medical Director stated the Potassium CL should not have been crushed but would not cause the resident any adverse effects.",2020-09-01
216,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,812,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure expired liquid protein supplements were not available for resident use in 1 medication cart of 4 medication carts observed. The findings include: During observation of the 200 hallway East side medication cart on [DATE] at 8:50 AM, two 30 ounce bottles of sugar free liquid protein, both bottles 1/2 full, with an expiration date of [DATE], was on the cart. During an interview on [DATE] at 8:54 AM, Licensed Practical Nurse (LPN) #1 confirmed both bottles of liquid protein expired on [DATE] and were available for resident use. During an interview on [DATE] at 2:18 PM, the Director of Nursing confirmed the facility had not removed 2 expired protein supplements from the 200 hallway East side medication cart.",2020-09-01
217,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,849,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain and maintain a hospice plan of care and hospice visit notes in the medical record for 1 of 3 residents (Resident #127) reviewed for hospice needs. The findings include: Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#127 was admitted to hospice care. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #127 had severe cognitive impairment and received hospice services. Review of the medical record showed no documentation of a hospice care plan or hospice visit notes for Resident #127. During an interview on 1/29/2020 at 1:26 PM, Licensed Practical Nurse (LPN) #3 confirmed the hospice care plan and the visit notes for Resident #127 were not maintained on the resident's medical record. During an interview on 1/29/2020 at 2:23 PM, the Director of Nursing confirmed the hospice care plan and visit notes were not maintained on Resident #127's medical record.",2020-09-01
218,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2017-05-24,309,D,1,0,YFPH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interview, the facility failed to administer medications as ordered for 1 Resident (#2) of 3 residents reviewed. The findings included: Review of the facility policy, Medication Pass Times, not dated revealed medications ordered to be administered at bedtime will be given at 9:00 PM. Continued review revealed medications ordered to be administered BID (twice a day) will be given at 9:00 AM and 9:00 PM. Medical record review revealed Resident #2 was admitted to the facility for Orthopedic Aftercare on 5/9/17. [DIAGNOSES REDACTED]. The resident was discharged from the facility and transported by the resident's daughter (complainant) to another facility on 5/18/17. Medical record review of a Nurses Note dated 5/9/17 and timed 10:20 PM, revealed Resident #2 was alert and oriented to person, place, and situation. Continued review revealed the resident required 2 person assistance for Activities of Daily Living, toileting, and transfers. The resident was able to feed self with tray setup. Medical record review of Physician's Orders dated 5/2017 revealed .[MEDICATION NAME] (medicine for [MEDICAL CONDITION]) 100 MG (milligrams) CAPSULE Give one capsule .twice a day .AMPYRA (medicine for MS) ER (extended release) 10 M[NAME] Give one tablet .twice a day .[MEDICATION NAME] (antibiotic) 250 MG TABLET. Give one tablet .every evening at bedtime .Montelukast Sod (sodium)(medicine for allergies [REDACTED].every evening at bedtime . Medical record review of an electronic Medication Administration Record [REDACTED]. Interview with the Director Of Nursing (DON) on 5/23/17 at 4:15 PM, in the DON's office confirmed the 9:00 PM medications were not administered within the expected time frame of 1 hour prior to and 1 hour after the ordered administration time on 5/13/17 for Resident #2 and confirmed the facility failed to follow the physician's orders.",2020-09-01
219,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2017-11-15,314,D,0,1,ED6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility protocol, medical record review, observation, and interview, the facility failed to implement interventions for the treatment of [REDACTED].#106) of 3 residents reviewed for pressures ulcer of 26 residents reviewed. The findings included: Review of the facility protocol Wound and Skin Care Protocols revealed .Purpose: .2. To prevent pressure ulcer formation by identifying those .who are high risk for pressure ulcers and to develop appropriate interventions. 3. To promote healing of pressure ulcers .Preventative Measures for guest (resident) scoring 17 or less on the Braden Scale. A .Guest will be repositioned every 2 hours if they are unable to position themselves .Suspected Deep Tissue Injury-depth unknown .Purple or maroon localized area of discolored intact skin .due to damage of underlying soft tissue from pressure .The wound may further evolve and become covered by thin eschar (dead tissue) . Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 required extensive assistance of 1 person for bed mobility and transfer. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance of 2 persons for bed mobility. Medical record review of Nurses Notes revealed the following: 8/22/17 - .admitted for skilled services PT/OT (physical and occupational therapy) .Alert and Oriented x1 (to person) with confusion .Heels soft red but blanchable .Braden (score of the facility's skin risk assessment tool) 16 . 10/27/17 - Weekly skin assessment .No open areas No ulcers No pressure Heels are clear . 11/3/17 - Weekly skin assessment .L (left) and R (right) outer heel pink but blanchable. Heel guards and skin prep in place. 11/7/17 - .9:36 PM .Called to room per CNA (certified nursing assistant). Skin concern noted to right lateral heel. 6.0 cm (centimeter) L (length) x (by) 4.0 cm W (width) non open area of non blanchable [DIAGNOSES REDACTED] (periwound) with a 2.0 cm L x 2.0 cm W non open black/purple area in center . Medical record review of the Wound Care Nurse assessments revealed the following: 8/23/17 - .Bilateral heels red sluggish blanching skin .Heels to be floated off surface on pillows while in bed . 11/8/17 - .right lateral heel new area SDTI measuring 2.5 x 2.0 cm. Skin intact dark blue purple in color. Periwound (area surrounding the pressure ulcer) blanching [DIAGNOSES REDACTED] . 11/14/17 - Wound care follow up right heel SDTI. Area larger in size, measures 2.5 x 5.0 cm. Dark red purple in color, skin intact. Periwound sluggish blanching red skin .continue current treatment and offloading on pillows . Medical record review of the physician's orders [REDACTED]. 11/7/17 - Dietary Consult for new pressure area .Float heels when in bed or chair as pt (patient) allows. 11/8/17 - Wound care assessment SDTI Rt (right) heel. Treatment initiated. Medical record review of the Comprehensive Care Plan, dated 8/22/17 revealed .Potential for skin breakdown associated with decreased mobility .Approaches .Reposition q (every) 2 hrs (hours) .11//8/17 - Pressure area to Rt (right) heel .Approaches .Encourage resident to float heels while in bed . Further review revealed floating the heels when in chair was not included as ordered on [DATE]. Medical record review of the bedside Care Plan provided for the CNA staff revealed a Task List including float heels off surface on pillows while in bed . Further review revealed floating the heels when in chair was not included. Observations of Resident #106 revealed the following: 11/13/17 at 10:30 AM, revealed the resident seated in a reclined chair with both heels laying directly on the footrest of the recliner, heels were not floated. 11/14/17 at 12:35 AM, with the Wound Care Nurse, revealed the resident seated in the reclining chair with both heels laying directly on the footrest of the recliner, heels were not floated. 11/15/17 at 10:15 AM, revealed the resident lying in the bed with both heels resting on the mattress, heels were not floated. Observation and interview with the Licensed Practical Nurse (LPN) #1 on 11/15/17 at 10:30 AM, in Resident #106's room, confirmed the resident's heels were not floated off of the mattress of the bed. Observation continued and LPN #1 uncovered the resident's feet, placed feet on a pillow with the heels resting on the pillow, not floated. Interview continued and LPN #1 stated Once up .stays up in the recliner most of the day (referring to the dayshift hours). Interview with the NP on 11/15/17 at 9:30 AM, in the conference room, revealed Resident #106 had been .in and out of the facility in the past . and when admitted [DATE] wasn't doing well at first .stabilized now . Interview continued and the NP confirmed the resident's overall health status had shown some improvement. Further interview confirmed the resident had a right heel pressure ulcer identified on 11/7/17 and the pressure ulcer had increased in size from 11/7-11/14/17. Interview with the Wound Care Nurse on 11/15/17 at 1:20 PM, in the conference room, revealed Resident #106 had prolonged periods of lethargy and the nurse stated this contributed to the resident lying on her back with the right heel rotated out laterally. Interview continued and confirmed the following: the Wound Care Nurse had not been aware the resident was in the reclined chair each day; the heels were not floated on 11/14/17 when resident was in the chair; the observation of LPN #1 placing Resident 106's feet on a pillow at 11:00 AM was not floating the heel, .when her heel is touching something there isn't pressure relief .; and the pressure ulcer identified as a SDTI on 11/7/17 had increased in size of width by 3 cm over the previous 7 days. Interview with the Director of Nursing on 11/15/17 at 2:45 PM, in the conference room, confirmed Resident #106's Comprehensive Care Plan included an intervention to float heels off of the bed, but did not include when in the chair, as ordered on [DATE]. Interview continued and confirmed the bedside CNA care plan did not include floating the heels while in the chair. Further interview confirmed the facility failed to implement interventions for the treatment of [REDACTED].",2020-09-01
220,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,578,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, and interview, the facility failed to ensure accuracy of advanced directives for 1 resident (#138) of 43 sampled residents. The findings include: Review of the facility's POST Form (Physicians Orders for Scope of Treatment - an advanced directive form that describes the health care wishes for someone facing a life-threatening medical condition) Policy and Procedure, undated, revealed .Once the POST form has been adequately filled out, it will be signed by the DPOA (Durable Power of Attorney)/surrogate and/or resident .placed in the chart .If the POST form is present on admission from an outside facility .If a physician's signature is present, no further action is necessary. It will remain in the resident's chart . Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #138's current care plan dated [DATE] revealed .Code Status DNR (Do Not Resuscitate) .Will have comfort measures ongoing as needed .educate staff on DNR status .Label Chart of DNR status . Medical record review of Resident #138's current POST form (from an outside facility) dated [DATE], revealed the CPR (Cardiopulmonary Resuscitation) box checked, indicating the resident would receive CPR if the resident had no pulse and was not breathing. Medical record review of the physician recapitulation orders dated (MONTH) (YEAR) revealed .DNR . Observation and interview with Licensed Practical Nurse (LPN) #5 on [DATE] at 9:56 AM, at the 4th floor nurse's station, revealed a DNR sticker on Resident #138's physical chart. Continued observation revealed the current POST form indicated the resident was to be resuscitated. Continued interview with LPN #5 confirmed the hospital may have changed the resident's code status but the resident remained a DNR status at the facility. Interview with the Director of Nursing on [DATE] at 4:09 PM, in the conference room, confirmed Resident #138's physician's recapitulation orders, code status sticker, and current care plan did not reflect the status indicated on the resident's current POST form .it (POST form) should be looked at and addressed . Continued interview confirmed the resident's advanced directives were inaccurate and the facility failed to follow facility policy.",2020-09-01
221,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,641,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (#23, #142) of 34 residents reviewed for MDS assessment of 43 residents sampled. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's Care Plan (resident's current care plan) dated 7/6/16 revealed the resident was care planned for potential for sad and or declining mood related to nursing home admission and health issues. Continued review revealed .5/7/18 NP (Nurse Practitioner) eval (evaluation) of behaviors and review of meds (medications) Add dx (diagnosis): [MEDICAL CONDITION] . Medical record review of a Nurse Practitioner Progress note dated 5/7/18 revealed .Seen for f/u (follow-up) confusion, delusions . conts (continues) with behaviors . Continued review revealed .Problem NEW to examiner [MEDICAL CONDITION] .[MEDICATION NAME] (antipsychotic medication) 25mg (milligram) qhs (every night) .12.5mg q (every) am (morning) Psych (psychiatric) f/u . Medical record review of a Psychiatric Consult dated 5/17/18 revealed .long term resident seen today for follow up .Staff report patient is still hallucinating at times . Continued review revealed Resident #23 was ordered [MEDICATION NAME] for the [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status Score of 3 indicating the resident was severely cognitively impaired. Continued review revealed in the Behavior Section of the MDS no documentation Resident #23 had exhibited any delusions during the quarterly review time period and no documentation of the [MEDICAL CONDITION]. Interview with the MDS Coordinator on 11/15/18 at 10:45 AM, in the conference room, confirmed the facility failed to accurately complete a quarterly MDS for Resident #23 to include the [DIAGNOSES REDACTED]. Continued interview confirmed the facility failed to document Resident #23's delusions in the behavior section of the MDS. Medical record review revealed Resident #142 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE], the 14 day MDS dated [DATE], and the MDS dated [DATE], did not indicate the resident was receiving [MEDICAL TREATMENT]. Interview with Licensed Practical Nurse, (LPN) #3 on 11/15/18 at 12:35 PM, in the conference room, confirmed the 3 MDS assessments dated 9/24/18, 9/30/18, and 10/22/18, did not reflect the resident was receiving [MEDICAL TREATMENT] and were not accurate.",2020-09-01
222,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,644,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to resubmit a pre-admission screening and resident review (PASARR) Level 1 for 1 resident (#23) of 8 residents reviewed for PASARR Level 2 evaluations of 43 residents sampled. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's PASARR Level 1 dated 7/15/11 revealed the facility submitted a PASARR Level 1 which was negative for PASARR Level 2 services. Medical record review of Resident #23's Care Plan (resident's current care plan) dated 7/6/16 revealed the resident was care planned for potential for sad and or declining mood related to nursing home admission and health issues. Continued review revealed .5/7/18 NP (Nurse Practitioner) eval (evaluation) of behaviors and review of meds (medications) Add dx (diagnosis): [MEDICAL CONDITION] . Medical record review of a Nurse Practitioner Progress note dated 5/7/18 revealed .Seen for f/u (follow-up) confusion, delusion . conts (continues) with behaviors . Continued review revealed .Problem NEW to examiner [MEDICAL CONDITION] . [MEDICATION NAME] (antipsychotic medication) 25mg (milligram) qhs (every night) .12.5mg q (every) am (morning) Psych (psychiatric) f/u . Medical record review of the Psychiatric Consult dated 5/17/18 revealed .long term resident seen today for follow up . Staff report patient is still hallucinating at times . Continued review revealed Resident #23 was ordered [MEDICATION NAME] for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 11/15/18 at 10:22 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #23 after the resident received a new [DIAGNOSES REDACTED].",2020-09-01
223,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,689,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documentation, observation, and interview, the facility failed to ensure a safety device was functional for 1 resident (#88) of 5 residents reviewed for falls. The findings include: Medical record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE] revealed the resident was at risk for falls. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognitive skills, did not walk, and had no falls since admission to the facility. Medical record review of the Care Plan reviewed on 9/11/18 revealed .At risk for Falls r/t (related to) generalized weakness .PSA (personal safety alarm) to bed . Medical record review of the physician's recapitulation orders for 11/2018, revealed the resident was to have a PSA when in bed. Medical record review of a nursing note dated 11/5/18 revealed At approx (approximately) 9pm resident was witnessed laying in floor beside bed on floor mat. When asked about what happened resident stated 'I am trying to get up and go downstairs.' No injuries apparent, resident has no c/o (complaints of) pain or discomfort. When assisted back into bed resident stated 'You're just wasting your time. I'm going to get back up again.' .Daughter is aware of fall. Review of facility's fall investgation, for the fall on 11/5/18, revealed the PSA did not alarm at the time of the fall on 11/5/18. Observation on 11/15/18 at 1:05 pm revealed the resident lying on a low bed, with a curved mattress, bilateral floor mats and a PSA in place. Interview with the Assistant Director of Nursing (ADON) on 11/14/18 at 1:20 PM, in the conference room, confirmed when the resident fell from the bed on 11/5/18, the PSA did not sound.",2020-09-01
224,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,758,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of a [MEDICAL CONDITION] medication for 1 resident (#51) of 6 residents reviewed for unnecessary medications of 43 residents sampled. The findings include: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of the Quarterly Minimum Data set ((MDS) dated [DATE] revealed Resident #51 had Dementia, Depression, and a [MEDICAL CONDITION]. Further review revealed Resident #51 received antipsychotic and antianxiety medications all 7 days of the 7 day lookback period, and no GDR had been attempted. Continued review revealed a GDR had not been documented by a physician as clinically contraindicated. Medical record review of the (MONTH) (YEAR) physician's orders [REDACTED]. Medical record review of a handwritten document from the facility's Consultant Pharmacist dated 11/15/18 revealed .a medication regimen review has been completed monthly for (Resident #51). Further review confirmed .I have not made a GDR recommendation to the prescriber . Interview with Registered Nurse (RN) #1 on 11/15/18 at 9:16 AM, in the Conference Room confirmed a GDR was not completed. Telephone interview with the Mental Health Nurse Practitioner on 11/15/18 at 10:00 AM, in Conference Room confirmed an [MEDICATION NAME] GDR was not attempted. Interview with Director of Nursing (DON) on 11/15/18 at 1:475 PM, in the DON's office confirmed there wasn't a GDR completed and there was no documentation that a GDR was contraindicated.",2020-09-01
225,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,761,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, and interview, the facility failed to discard expired medications/supplies in 1 of 3 medication carts and in 3 of 4 medication storage rooms. The findings include: Review of the facility policy, Medication Storage, dated 8/1/15, revealed .All out-dated, deteriorated, or unusable drugs shall be stored in a designated area away from other drugs . Observation of the medication cart and interview with Licensed Practical Nurse (LPN) #1 on 11/15/18 at 10:05 AM, in the 300 unit medication cart room revealed 1 opened bottle of glucose testing strips, 1/2 full, expired on 10/11/18. Interview with LPN #1 confirmed the glucose testing strips were expired and available for resident use. Observation and interview with LPN #2 on 11/15/18 at 10:15 AM, in the 300 unit medication storage room, revealed the following supplies expired and available for resident use: 11 blood specimen collection needles with an expiration date of 5/2017. Interview with LPN #2 confirmed the supplies were expired and available for resident use. Observation and interview with LPN #4 on 11/15/18 at 1:20 PM, of the 400 hall medication room, confirmed there were 5 [MEDICATION NAME] acetate suppositories, with an expiration date of 7/2018, available for resident use.",2020-09-01
226,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,880,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to follow infection control guidelines during meal service on 1 of 4 floors. The findings include: Review of facility Personal Hand Sanitization Policy (undated) revealed .All employees will use waterless hand rub or soap and water to clean their hands: .Before having direct contact with residents .After contact with a resident's intact skin .After contact with inanimate objects in the immediate vicinity of the resident . Observation of Certified Nursing Assistant (CNA) #1 on 11/13/18 at 12:40 PM, on the 400 unit, revealed CNA #1 entered room [ROOM NUMBER]. Further observation revealed inside the room, CNA #1 touched the wheelchair then exited room without performing hand hygiene. Continued observation revealed CNA #1 then entered room [ROOM NUMBER], pulled up the resident in bed, and touched the blanket. Further observation revealed CNA #1 exited room [ROOM NUMBER] without performing hand hygiene, removed a meal tray from the cart in the hall, then entered room [ROOM NUMBER] and placed the meal tray on the bedside table. Continued observation revealed, CNA #1 then exited room [ROOM NUMBER] without performing hand hygiene and knocked on the door to room [ROOM NUMBER]. Further observation revealed CNA #1 removed a meal tray from the cart in the hall and carried it into room [ROOM NUMBER]. Continued observation revealed CNA #1 set up the meal tray, then touched the table and exited the room without performing hand hygiene. Interview with CNA #1 on 11/13/18 at 12:46 PM, on the East 400 hall, confirmed she hadn't washed her hands before she handed out the meal trays. Interview with Director of Nursing (DON) on 11/14/18 at 2:58 PM, in DON's office confirmed she expected staff .to wash hands before you go in a room, before you go out of a room, anytime you are going in and out of somebody's room . Continued interview confirmed .I would expect them to wash their hands .",2020-09-01
227,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-02-07,655,D,0,1,UOI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's Drug Information Report, medical record review, observation, and interview, the facility failed to provide an interim plan of care for 1 resident (#91) of 45 residents reviewed. The findings included: Review of the Drug Information Report provided with the electronic Information Medication Administration Record [REDACTED].[MEDICATION NAME] (medication to treat heart arrhythmias).it can.cause a new serious abnormal heart rhythm (QT prolongation (indicator of a delay in repolarization of the heart).). This problem can lead to a new type of abnormal (possibly fatal) heartbeat (torsade de pointes). If this new serious heart rhythm occurs, it is usually when [MEDICATION NAME] treatment is first started.This medication is used to treat a serious (possibly life-threatening) type of fast heartbeat. Medical record review revealed Resident #91 was admitted to the facility on [DATE] following an acute care hospital stay 11/16/17 through 11/30/17 with a new onset of [MEDICAL CONDITION] Fibrillation (A-Fib). Medical record review of the hospital cardiology note dated 11/30/17 revealed, .[MEDICATION NAME] started yesterday (11/29/17) has put pt (patient) back in NSR (normal sinus rhythm).if pt stays in NSR on [MEDICATION NAME], cardioversion will be canceled. Medical record review of the facility's Baseline Care Plan dated 11/30/17, revealed .Clinical Reason for Admission.[MEDICAL CONDITION] Fibrillation. Continued review revealed the drug [MEDICATION NAME], prescribed for Resident #91 on 11/29/17, 1 day prior to admission, wasn't included as a Care Need. Medical record review of the physician's orders [REDACTED]. Record review of the following 12/4/17 physician's orders [REDACTED]. [MEDICAL CONDITION].[MEDICATION NAME] [AGE] mg (milligrams) BID (twice a day).High risk of brady (low heart rate) torsade (torsade de pointes) 2 (secondary to) acquired (increased) QT. Medical record review of a nursing entry dated 12/4/17 at 2:49 PM revealed the resident was transferred by ambulance to the local acute care hospital, .unstable.P (pulse) 53. Medical record review of the hospital cardiology consult dated 12/5/17, revealed .I reviewed the EKG that was performed on 1[DATE]17 demonstrating sinus [MEDICAL CONDITION] with ventricular rate of 51 beats per minute. Medical record review of the hospital's transfer to Nursing Home Orders dated 12/11/17, revealed the drugs [MEDICATION NAME] and [MEDICATION NAME] had been discontinued and instructions to .Remove foley (indwelling urinary catheter) 1/1/18 at HS (bedtime) for urology appointment the following day. Medical record review of the facility's Baseline Care Plan dated 11/30/17, revealed the resident's return to the hospital on [DATE] through 12/11/17 was not included, the new [DIAGNOSES REDACTED]. Observation of Resident #91 on 2/5/18 at 10:25 AM, revealed the resident was napping in bed. Interview with Licensed Practical Nurse (LPN) #1, self-identified as an Administrative Nurse, on 2/7/18 at 3:15 PM, in the conference room, confirmed the resident's Baseline Care Plan did not include the use of [MEDICATION NAME], the precautions (especially when [MEDICATION NAME] is newly prescribed), or any cardiac assessments required for safe administration. Continued interview confirmed the complication of [MEDICAL CONDITION] was recognized by the physician extender during an initial assessment of Resident #91 on 12/4/17. Continued interview confirmed the resident's hospital stay 12/4/17-12/11/17 wasn't reflected in the Baseline Care Plan dated 11/30/17, the Baseline Care Plan wasn't reviewed or revised when the resident returned after a 7 day hospital stay, and the plan of care did not include the indwelling urinary catheter upon return from the hospital.",2020-09-01
228,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-02-07,689,D,0,1,UOI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility fall investigation, observation, and interview, the facility failed to implement new interventions to prevent future falls for one Resident (#101), of 5 residents reviewed for falls, of 45 residents reviewed. The findings included: Review of facility policy Falls Policy, not dated, revealed, .Treatment/Management.1. Based on the preceding assessment, the staff, and/or physician will identify.pertinent interventions to try to prevent subsequent falls and address the serious consequences of fall.Monitoring/Follow-up.2. The staff will monitor and document the individual's response to interventions intended to reduce falling or consequences of falling. Medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Interim Care Plan Addendum dated 4/21/17 revealed, .At risk for falls related to.h/o (history of) falls, unsteady gait. Continued review revealed, .Nursing Interventions.orient the resident to room, bed controls, light and call-light.Instruct and remind the resident to use call-light to ask for assist.Keep path around the bed and to the bathroom clear from clutter. Medical record review of the High Risk Patient Selection Form, not dated, revealed an admission assessment for risk for falls. Continued review revealed the resident was assessed as a fall risk due to falling in past the 30 days with interventions to include therapy screening, wheelchair assessment and walking assessment. Medical record review of the resident's current care plan dated 5/11/17 revealed, .Resident at risk for falls secondary to: difficulty in walking, dementia. Continued review revealed, .Approaches.monitor resident for poor safety awareness.keep pathways free from clutter.keep wheelchair locked during transfers.educate resident on up with assistance only.non-skid footwear (which was marked out with a line through it).keep call light within reach.monitor environment for safety.maintain bed at lowest level for safety.fall precautions. Medical record review of a Post Falls Nursing assessment dated [DATE] revealed the resident had a fall on 5/31/17 at 7:00 PM in the resident's bathroom.CNA (certified nursing assistant) yelled help. Went to see what was going on. CNA reported patient was on the floor in the bathroom.Exiting commode while unattended.Patient states he used grab bars to stabilize himself to the floor when he got his legs twisted up. He did have an abrasion to left rib area. Continued review revealed, .Patient's position after the fall?.Patient was found on the floor sitting on his bottom up against the wall between the toilet and wheelchair.Patient has an abrasion to the rib area going up his side. Medical record review of Nurse's Notes dated 6/1/17 revealed, .Follow-up for event on 5/31/17. Resident was attempting to transfer self from toilet to chair. His feet got tangled.he stabilized himself to floor. Medical record review of a Nurse's Note dated 6/6/17 revealed, .Follow-up note for previous fall on 5/31/17.Spoke with Rt (resident) concerning fall. Rt stated he attempted to transfer from toilet to wheelchair unattended and his legs got twisted up in catheter tubing. He states he was able to stabilize himself to the floor. Reinforcement of use of call light and asking for assistance when transferring. Will continue to monitor. Medical record review of a Nurse's Note dated 11/29/17 and timed 6:50 PM, revealed, .Called to pt's (patient's) room. Observed pt lying on his left side in the bathroom with blood pooled under his head. After raising pt up a large laceration was noted to his left ear.pressure dressing was applied.pt was transferred to w/c (wheelchair).order to send to ER for evaluation. Medical record review of Post Falls Nursing assessment dated [DATE] revealed, .called to pt's room, observed pt lying on his left side in the bathroom.fell from wheelchair.trying to go to the bathroom. Continued review revealed, .What immediate interventions were initiated to prevent future falls.Pressure alarm to chair and frequent observation started. Review of the resident's care plan revealed the intervention to add pressure alarm was not added to the resident's care plan. Medical record review of a Nurse's Note dated 12/1/17 at 2:00 PM, revealed .Follow up for event (fall) on 11/29/17.Patient is alert and oriented x 4 (to person, place, time, and situation) c (with) BI[CONDITION] (Brief Interview for Mental Status) score of 15 (no cognitive impairment) on 10/23/17. At time of event patient continued to be cognitively intact. Patient stated he was toileting himself when he fell .Patient is anticipated to return to facility once medically stable. Review of a Post Falls Investigation dated 12/1/17 revealed, .Will assess need for interventions upon return to facility. Observation of the resident on 2/6/18 at 2:00 PM, in the resident's room, revealed the resident laying in the bed and sleeping. Continued observation revealed no pressure pad alarms in place. Interview with LPN #1 and observation of the resident on 2/6/18 at 2:05 PM, in the resident's room, confirmed no pressure pad alarms were in place. Interview with the Falls Nurse and Director of Nursing (DON) on 2/7/18 at 1:06 PM, in the Falls Nurse's office, confirmed the Falls Nurse was unaware of the intervention to add a pressure pad alarm to the resident's chair after the resident's fall on 11/29/17. Continued interview with the Falls Nurse confirmed the Falls Nurse had not reassessed the resident or implemented any additional falls interventions to prevent future falls when the resident returned to the facility after hospitalization for the fall that occurred on 11/29/17.",2020-09-01
229,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,689,D,0,1,IS2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident Assessment Instrument Manual (RAI), facility policy review, medical record review, observation, and interview the facility failed to identify falls and complete a fall investigation for 1 resident (#118) of 5 residents reviewed for falls of 33 sampled residents. The findings include: Review of the RAI manual (3.0 version) dated 10/2018, (J1700: Fall) revealed .Fall unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed mat, chair, or bedside mat) .identified when a resident is found on the floor or ground . Review of the facility policy Falls revised 7/14/2017, .Cause Identification 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .3. The staff and /or physician will continue to collect and evaluate information until either the cause of the falling is identified . Medical record review revealed Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was at high risk for falls. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severly impaired cognitive skills; required extensive assist of 2 persons for bed mobility and transfers; and extensive assist of 1 person for dressing, eating, toilet use, and personal hygiene. Medical record review of the nurses notes for the following dates revealed: 8/8/18-fell from bed, no apparent injuries. 11/11/18-found with bottom on fall mat and upper body/head on bed, no injuries. 11/24/18-found kneeling next to bed holding onto bed rail, no injuries. 2/10/19-fall on 2/9/19 found on mat, no injuries. Continued medical record review revealed there was no documentation of a facility fall assessment or fall investigation for the falls on 11/11/18 and 2/9/19; and no fall investigation for the 11/24/18 (there was a fall assessment completed). Interview with the Risk Manager on 2/11/19, 2:40 PM in the day room revealed when the resident was found to be on the fall mats, it was not considered to be a fall. Continued interview with the Risk Manager revealed the Resident had not sustained any injuries. Further interview with the Risk Manager in the day room, confirmed fall investigations had not been completed on 11/11/18, 11/24/18 and 2/9/19 on 3 of the 4 falls listed. Observation on 2/12/19, at 8:35 AM and 9:40 AM, revealed Resident #118 was lying in bed. Continued observation revealed the bed was in low position and floor mats in place. Interview with the Director of Nursing on 2/12/19 at 9:25 AM, in the 2nd floor day room confirmed all falls are to be assessed and investigated with new interventions put in place to prevent further occurrences.",2020-09-01
230,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,698,D,0,1,IS2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to remove a pressure dressing per the Physician's Order for 1 (#68) of 2 residents reviewed of 3 residents receiving [MEDICAL TREATMENT] of 33 residents sampled. The findings include: Medical record review revealed Resident #68 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 had a Brief Interview for Mental status score of 13, indicating he was cognitively intact. Further review revealed the resident received [MEDICAL TREATMENT] treatments (process of removing excess water and toxins from the blood in people whose kidneys can no longer perform this function) on a routine basis. Medical record review of the Complete Patient Care Plan updated 1/8/19 revealed .I receive [MEDICAL TREATMENT] (form of [MEDICAL TREATMENT]) .remove pressure dressing (dressing applied over the [MEDICAL TREATMENT]) post (after) [MEDICAL TREATMENT] days per md (physician) orders . Medical record review of the Physician's Orders dated 2/1/19-4/30/19 revealed .[MEDICAL TREATMENT] .REMOVE PRESSURE DRESSING POST [MEDICAL TREATMENT] DAYS 4-6 (hours) AFTER RETURNING FROM [MEDICAL TREATMENT]. MONDAY WEDNESDAY AND FRIDAY . Observation and interview with Resident #68 on 2/12/19 at 8:03 AM, in the resident's room revealed the resident lying on the bed with the pressure dressing in place over the access site on the right upper arm. Further interview with the resident revealed the pressure dressing had not been removed after he returned from the [MEDICAL TREATMENT] clinic on the previous day (2/11/19). Observation and interview with the Licensed Practical Nurse (LPN) Supervisor on 2/12/19 at 8:07 AM, in the resident's room confirmed the pressure dressing was in place to the right upper arm [MEDICAL TREATMENT]. Further interview confirmed the dressing should have been removed on 2/11/19 after the resident returned from the [MEDICAL TREATMENT] clinic. Interview with the LPN Supervisor on 2/12/19 at 2:43 PM, at the 2nd floor nurse's station confirmed Resident #68 had returned to the facility from the [MEDICAL TREATMENT] clinic on 2/11/19 at 6:56 PM. Further interview confirmed the pressure dressing should have been removed by 11:00 PM on 2/11/19 per the Physician's Order. Interview with the Risk Manager on 2/12/19 at 2:59 PM, in the Risk Manager's office confirmed the facility failed to remove Resident #68's pressure dressing per Physician's Order.",2020-09-01
233,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-05-21,609,D,1,0,JKQQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review and interviews, the facility failed to ensure an allegation of abuse was reported timely to the facility Administrator and to other officials (State Survey Agency and Adult Protective Services) in accordance with Federal and State law for 1 resident (#1) of 3 residents reviewed for Abuse on 3 nursing units for 3 sampled residents. The findings included: Review of facility policy Patient Protection and Response Policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed .6. Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse . Review of a facility investigation dated 4/30/19 revealed Certified Nursing Assistant (CNA) #2 reported to the charge nurse on 4/30/19 she witnessed possible abuse by CNA #1 toward Resident #1 on the evening of 4/29/19. Continued review revealed the charge nurse notified Administration of the allegation and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) interviewed CNA #2. Further review revealed CNA #2 reported she witnessed CNA #1 grab the arm of Resident #1 and forcefully push her back into her wheelchair with an open hand. 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 was severely cognitive impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility and extensive assistance of 1 person for transfers. Telephone interview with CNA #1 on 5/21/19 at 10:20 AM revealed she put her hands on the shoulder of the resident to ease her back into her chair because she was afraid the resident would fall. Interview with the Administrator on 5/21/19 at 10:50 AM, in the Conference Room, confirmed the facility failed to report an allegation of abuse within 2 hours and failed to follow facility policy.",2020-09-01
234,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-08-16,609,D,1,0,Y10D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure an allegation of abuse was reported timely to the state agency for 1 resident (#3) of 3 residents reviewed for abuse of 3 sampled residents. The findings included: Review of facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation revised 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 .are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #3 was admitted to the facility 12/8/12 with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was moderately cognitive impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Review of a facility investigation dated 7/25/18 revealed on 7/25/18 at approximately 3:30 PM Resident #3 reported to her granddaughter a Certified Nursing Assistant (CNA) had gotten irritated with her, choked her, and threw water on her about a week ago. Continued review revealed the granddaughter reported the allegation to the nurse. Further review revealed the nurse interviewed Resident #3 and then reported the allegation to the appropriate administrative personnel, who initiated an investigation. Continued review revealed on 7/26/18 the resident changed her report of the incident and stated the CNA actually hit her on the leg, but did not choke her. Further review revealed the alleged incident was not reported to the state survey agency. Interview with the Director of Nursing (DON) on 8/16/18 at 1:00 PM, in the Conference Room, confirmed the facility failed to report the alleged incident to the state survey agency and the facility failed to follow facility policy.",2020-09-01
235,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,329,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, facility documentation, medical record review, and interview, the facility administered unnecessary medications for 2 residents (#3 and #24) of 15 residents reviewed for medication errors. The findings included: Review of the facility policy Preparation and General Guidelines dated 6/2016, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .The Medication Administration Record [REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation dated 8/10/17, revealed .Med (Medication) cart nurse .(Licensed Practical Nurse (LPN) #5) was on lunch break .(Resident #3) had a scheduled dose of [MEDICATION NAME] (narcotic pain medication) 10 mg (milligrams) due .patient's husband, requesting the medication be given .(Registered Nurse (RN) #2) .administered the medication .signed out of the narcotic count log and the IMAR (electronic medication administration record) .(LPN #5) returned from lunch, he (LPN #5) noted the medication would not scan in IMAR due to already being signed out but administered anyway (LPN #5 administered another dose) . Telephone interview with LPN #5 on 10/18/17 at 9:15 AM, revealed on 8/10/17, LPN #5 returned from lunch, obtained a dose of the scheduled [MEDICATION NAME] 10 mg for Resident #3, administered the medication, returned to the medication cart, began to sign out the narcotic on the resident's [MEDICATION NAME] record sheet, and noted the narcotic had already been signed out for the scheduled dose by RN #2. Continued interview confirmed LPN #5 had administered a second dose of [MEDICATION NAME] and reported the medication error to his Charge Nurse, RN #1. Further interview confirmed LPN #5 had not followed the facility's policy for safe medication administration. Interview with the Director of Nursing on 10/19/17 at 4:34 PM, in the conference room, confirmed Resident #3 received an unnecessary dose of [MEDICATION NAME]. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognitive abilities. Medical record review of the Nurse's Notes dated 10/26/17 for Resident #24, written by RN #4, revealed .8:30 PM Pt (patient) is screaming @ (at) the top of her lungs, combative, trying to throw herself into the floor. PRN (as needed) and scheduled [MEDICATION NAME] given (anti-anxiety medication) outcome not effective. Pt is threatening staff. (On call physician service) paged (on-call medical service) .NP (Nurse Practitioner) gave (an order to RN #4) .1 mg [MEDICATION NAME] IM (intramuscular) x1 dose now for increased agitation and combative behavior. Interview with RN #4 on 12/4/17 at 3:28 PM, in the conference room, confirmed the order for [MEDICATION NAME] had been initially written incorrectly for an oral dose and re-written incorrectly [MEDICATION NAME] 2MG/ML VIAL Give 1mg (1ml) IM .Verbal order .(on call physician service) . Further interview revealed RN #4 was counseled not to include concentrations when writing future orders. Telephone interview with LPN #8 on 12/4/17 at 3:43 PM confirmed RN #4 received the order for a 1 time dose of [MEDICATION NAME] 1 mg IM on 10/26/17 for Resident #24. Further interview revealed he borrowed from another resident's supply of [MEDICATION NAME] at 8:30 PM and incorrectly administered a 1ml (2 mg) IM dose to Resident #24. Further interview revealed LPN #8 did not use the [MEDICATION NAME] supplied in the facility's emergency medication box because he wanted to administer the [MEDICATION NAME] quickly. Continued interview revealed LPN #8 discovered the medication error during counting (reconciling the number of controlled medications at shift change) with the oncoming night shift nurse, there was a shortage of a half milliliter (0.5 ml in the 4 ml multi-dose [MEDICATION NAME] vial supplied by the pharmacy). During the interview, LPN #8 stated the sign out sheet for the [MEDICATION NAME] was reviewed for the first time during the counting procedure and he realized a double dose had been administered. Interview confirmed the pharmacy information printed on the [MEDICATION NAME] sign-out sheet read [MEDICATION NAME] 2 mg/ml .Inject 0.5-1mg (0.25-0.5 ml) . Continued interview confirmed LPN #8 had not read the information on the vial of [MEDICATION NAME] and administered 2 mg instead of the ordered 1 mg dose. Interview revealed the error was reported to RN #3, the night shift supervisor. Further interview revealed LPN #8 had participated in the facility-wide in-service conducted on 10/19/17 What Are the Eight Rights of Medication Administration Safety. Continued interview confirmed he did not follow the third right Right Dose when he administered the double dose of [MEDICATION NAME] on 10/26/17. Telephone interview with the night shift nursing supervisor, RN #3, on 12/5/17 at 11:08 AM, confirmed LPN #8 initially reported the medication error of 10/26/17 to her. Continued interview revealed I wasn't sure if I was the one responsible to report it (the medication error) to (on call physician service) .it happened 2-3 hours before I came on duty . Interview continued and confirmed RN #3 did not report the medication error to her supervisor on the morning of 10/27/17. Further interview confirmed RN #3 had not initiated the facility's Medication Error Checklist and Report after LPN #8 reported the medication error. Interview with the Assistant Director of Nursing on 12/4/17 at 2:42 PM, in the conference room, confirmed Resident #24 received a double dose of [MEDICATION NAME] and RN #3 failed to report the medication error to the on call physician and to initiate an incident report. Continued interview revealed the [MEDICATION NAME] order was transcribed incorrectly by RN #4 and confirmed nursing principles for accurate recording and transcription of telephone orders had not been shared with the facility's nurses who receive and transcribe orders.",2020-09-01
237,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,441,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility Infection Control Manual, review of the Infection Control Policy, medical record review, and interview, the facility failed to follow contact isolation infection control guidelines for 1 resident (#16) of 7 residents reviewed for Extended Spectrum Beta Lactamases (ESBL) (an antibiotic resistant micro-organism) in their urine. The findings included: Review of the facility Infection Control Manual revised 10/1/08, revealed .use Contact Precautions for patients known or suspected to be infected or colonized with epidemiologically significant microorganisms that can be transmitted by direct contact with patient or indirect contact with environmental surfaces or patient care equipment .Place the patient who contaminates the environment or who does not or cannot assist in maintaining appropriate hygiene or environmental control in a private room .May allow resident to stay with roommate if total care for transfers/mobility . Review of the Infection Control Policy for ESBL, VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]), MRSA (Methicillin-Resistant Staphylococcus Aureus) in the urine dated 9/26/17, revealed .initiate contact precautions .Resident may stay with roommate, if urine is contained . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 scored 5 out of 15 for the Brief Interview for Mental Status indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assist for most activities of daily living and was incontinent of bladder. Medical record review of Resident #15's Urinalysis Report dated 9/18/17 revealed .LEUK[NAME]YTE ESTERASE (white blood cells associated with infection) .LARGE . Medical record review of Resident #15's Microbiology Report dated 9/18/17 revealed .Urine .Escherichia coli (E.coli) .ESBL . Medical record review of the Care Plan dated 9/22/17 revealed Resident #15 was placed on contact isolation on 9/22/17. Further review revealed Resident #15's family requested the resident not be treated with antibiotics on 9/26/17. Medical record review of Resident #15's Nurse's Note dated 9/26/17 revealed .(urinary) catheter placed .ESBL urine contained . Medical record review revealed Resident #15 and Resident #16 were roomates at that time. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].coli, and Chronic Atrial Fibrillation. Medical record review of the MDS dated [DATE] revealed Resident #16 was unable to complete the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS revealed she required extensive assist for most activities of daily living. Medical record review of Resident #16's Nurse's Note dated 9/26/17 revealed .Family upset about pt (patient) being in bedroom c (with) pt in contact isolation. Pt moved to different room per family request .UA (urinalysis) obtained .per family request . Medical record review of Resident #16's Microbiology Report dated 9/26/17 revealed .URINE .Escherichia coli . Medical record review of Resident #16's Nurse's Note dated 9/30/17 revealed .Contact isolation initiated for ESBL .proteus mirabilis urine culture . Medical record review of the Care Plan dated 10/2/17 revealed Resident #16 was placed on contact isolation and had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #7 on 10/9/17 at 1:11 PM, at the 2nd floor nurses station, confirmed Resident #15 was placed on contact isolation on 9/22/17. Telephone interview with Resident #16's granddaughter on 10/9/17 at 7:19 PM confirmed .Asked her to be tested on Tuesday (9/26/17) .All the infected resident's stuff was on Grandmother side of room .Her (Resident #15) food tray .cups had been thrown on her side of the room .My grandmother used that resident's toilet .The other resident catheter was emptied in there .she (Resident #16) touched things in the room . Interview with Registered Nurse (RN) #1 on 10/10/17 at 9:50 AM, in the Director of Nursing (DON's) office, confirmed .She (Resident #16) is prone to get infections .She is a carrier of [DIAGNOSES REDACTED] (Clostridium difficile, a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) . Telephone interview with the Nurse Practitioner on 10/10/17 at 11:10 AM, confirmed .tested her (Resident #16) because in room with (Resident #15) .They both have E. coli and ESBL .The urine was contained in the brief . Interview with the Assistant Regional Nurse on 10/10/17 at 4:30 PM, in the conference room, revealed the facility felt the risk was minimal for Resident #16 and confirmed the Assistant Regional Nurse did not know why the facility had not planned to move Resident #16 on 9/26/17, when the other affected residents were moved. Interview with the Assistant Director of Nursing (Infection Control Nurse) on 10/16/17 at 9:50 AM, in the conference room, confirmed the facility failed to follow the facility policy by not moving Resident #15 to another room once she was diagnosed with [REDACTED].#16 to be exposed to ESBL during the dates of 9/18/17 through 9/26/17.",2020-09-01
239,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,502,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to obtain accurate laboratory results for 1 resident (#5) of 14 residents reviewed for medication errors. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED]. Medical record review of Physician order [REDACTED]. D5NS (5% [MEDICATION NAME] in normal saline intravenous) 200 cc (cubic centimeters) bolus, 125 cc/hr (hour) x1 liter. 20 (milligram) [MEDICATION NAME] ([MEDICATION NAME]) after bolus (5% [MEDICATION NAME] in normal saline) . Medical record review of the Medication and Treatment Administration Record Report dated 8/2017 revealed Resident #5 received a D5W 200 ml bolus at 2:33 PM on 8/29/17 and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg IV at 2:36 PM on 8/29/17 PM. Medical record review of the Medication and Treatment Administration Record Report dated 8/20/17 and the daily skilled Nurse's Notes did not reflect when the [NAME]exlate 30 mg PO now had been administered. Medical record review of physician progress notes [REDACTED].Repeat K (potassium) .waiting .will give IVF (intravenous fluids) .[MEDICATION NAME] . Medical record review of Physician order [REDACTED].DC (discontinue) PO (by mouth) K .[NAME]xelate (medication to lower Potassium levels) 30 mg . Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 (normal range 3.5-5.1) collected at 5:00 AM, released at 9:17 AM, and called as a critical level to the facility. Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 collected at 5:00 AM, released at 12:49 PM, and called as a critical level to the facility. Medical record review of Resident #5's Laboratory Report dated 8/29/17 revealed a potassium level of 4.4 collected at 9:57 AM, released at 12:14 PM, and not called to the facility. Interview with RN #2 on 10/18/17 at 1:25 PM, in the conference room, revealed, as the house supervisor on 8/29/17, her duties included calling critical lab values to the Physician following telephone notification by the lab. Further interview revealed an elevated potassium level of 7.3 was called to the Physician on 8/29/17 and a repeat blood draw to verify the potassium level was ordered. Continued interview revealed RN #2 received a second call from the lab for Resident #5 on 8/29/17, with a report of a critical potassium level of 7.3. Interview continued and confirmed Resident #5 received the now dose of [NAME]exlate. Further interview confirmed, when the printed copies of Resident #5's Chemistry Reports were received at the facility, RN #2 noted the repeated potassium value of 4.4 had not been called to the facility. Continued interview confirmed the repeat lab, drawn at 9:57 AM, requested by the Physician, indicated a potassium level of 4.4 and was not called to the facility. In summary, the facility did not receive telephone notification from the lab for the potassium level of 4.4, collected at 9:57 AM, by Physician order [REDACTED]. The facility did receive a second telephone notification of the critical potassium level of 7.3 (rerun as a lab quality control measure from the 5:00 AM blood sample). The nursing staff failed to identify whether the second critical potassium level called to the nursing home was obtained from the second blood specimen drawn. The second notification of the critical potassium level of 7.3 (exactly the same value as the first critical level) was acted on by the nursing staff and Resident #5 received [NAME]exlate to lower his potassium level.",2020-09-01
241,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,550,D,0,1,PNQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to treat 1 of 20 residents (Resident #25) reviewed for indwelling urinary catheters with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover. The findings include: Review of the medical record, showed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#25, showed .Suprapubic Catheter change Q (every) month on the 8th and PRN (as needed) . Observation in the resident's room on 2/18/2020 at 3:49 PM and on 2/19/2020 at 8:32 AM, showed Resident #25's indwelling urinary catheter bag was placed on the right side of bed facing the door, without a privacy cover. During an interview conducted on 2/18/2020 at 4:28 PM, Licensed Practical Nurse #1 confirmed Resident #25's indwelling urinary catheter bag was not placed in a privacy cover. During an interview conducted on 2/18/2020 at 4:39 PM, the Director of Nursing stated that her expectations were for the indwelling urinary catheter bags to be placed in a privacy cover while residents were up and about and when the catheter bags were facing the door when the residents were in their rooms.",2020-09-01
242,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,600,D,1,1,PNQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 2 of 2 residents (Resident #47 and Resident #[AGE]) involved in a resident to resident altercation. The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, showed physical abuse included slapping, pinching, and kicking. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Mininmum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status (BI[CONDITION]) score of 99 indicating severe cognitive impairment. Review of the medical record, showed Resident #[AGE] was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], showed Resident #[AGE] had a BI[CONDITION] score of 3 indicating severe cognitive impairment. Review of the facility investigation dated 1[DATE]19, showed Resident #47 was found in Resident #[AGE]'s room rearranging the sheets on Resident #[AGE]'s bed. Continued review showed the actions of Resident #47 scared Resident #[AGE] and she grabbed Resident #47's hands which caused a skin tear to her right hand. Resident #[AGE] had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on [DATE]20 at 8:35 AM, Family Member #2 stated, (named Resident #47) was aggressive and wandered into other resident's rooms and fought with other residents. During an interview conducted on [DATE]20 at 3:48 PM, Certified Nurse Aid (CNA) #3 stated she was walking to the dining room around 8:00 PM or 9:00 PM and she heard (named Resident #[AGE]) yell help. When she entered (named Resident #[AGE]'s) room (named Resident #[AGE]) was lying in bed and (Named Resident #47) was standing over (named Resident #[AGE]) and her wheel chair was right behind her. (named Resident #47) had (named Resident #[AGE]'s) blankets in her hands. Resident #[AGE] was grabbing the blankets and also grabbed (named Resident #47's) hands. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 stated (named Resident #47) got easily annoyed. During an interview conducted on 2/20/2020 at 5:22 PM, the Director Of Nursing confirmed there was a physical altercation between Resident #47 and Resident #[AGE] which resulted in a skin tear for Resident #47 and pain to the right hand resulting in a need for an Xray for Resident #[AGE].",2020-09-01
243,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,657,D,1,1,PNQL11,"**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 a care plan for 1 of 52 residents (Resident #47) reviewed for behaviors. The findings include: Review of the facility policy titled, Care Plan Development, revised 7/3/2008, showed care plans were updated as needed, and on quarterly basis within 7 days of completion of the Minimum Data Set (MDS) assessment. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status score 99 indicating severe cognitive impairment. Continued review showed Resident #47 had behaviors of wandering, hitting, kicking, pushing, scratching, and grabbing others. Review of the care plan dated 7/1/2019, 1[DATE]19, and 11/7/2019 showed no new behavior interventions for Resident #47. Review of the facility investigation dated 1[DATE]19 showed Resident #47 was found in Resident #[AGE]'s room rearranging the sheets on Resident #[AGE]'s bed. Continued review showed the actions of Resident #47 scared Resident #[AGE] and she grabbed Resident #47's hands which caused a skin tear the right hand. Resident #[AGE] had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 confirmed the behavioral care plan for Resident #47 was not updated to reflect behaviors prior to the resident to resident incident on 11/3/2019.",2020-09-01
244,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,584,D,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to maintain a safe and orderly environment in 1 resident room of 50 resident rooms on the first floor. Findings include: Review of facility policy,Housekeeping Cleaning Schedule, Daily undated revealed .Patient Rooms .Damp dust all horizontal and vertical surfaces of patient furniture .Remove clutter and arrange furniture neatly .Damp dust all light fixtures, window sills, blinds, etc. with disinfectant solution .Spot clean walls . Observation of room [ROOM NUMBER] on 2/27/18 at 12:09 PM revealed an unsampled resident in bed near the door with a BIMS( Brief Interview of Mental Status) of 99 and none interviewable. Continued observation revealed the resident's family member was sitting in a chair. Further observation revealed there was narrow access around the resident's bed. Continued observation revealed multiple items were present in the room in cardboard boxes and plastic totes lining all of the walls around the perimeter of the room extending into the normal walkway and the entire area was extremely cluttered. Observation revealed a bed was in the corner of the room with cardboard and plastic containers, creating only a narrow access around the bed to bathroom, sink and commode. Boxes were lining all the walls around the perimeter extending into the walkway; the shower also had boxes stacked from the floor to the ceiling. Observations of room [ROOM NUMBER] on 2/27/18 at 3:00 PM and 2/28/18 11:00 AM revealed the same continued cluttered and unsafe environment. Interview with Registered Nurse (RN) #3 at the West Nurse station on 2/28 12:00 PM revealed several staff members had asked the resident's family to remove the clutter, boxes, etc. and she would not comply with the request. Continued interview with RN #3 states it was s safety issue for the resident with all the clutter in the room and having to walk around the multiple objects presents a unsafe environment. Interview with Certified Nurse Assistant (CNA) #5 on 2/27/18 at 1:00 PM at the West Nurse's Station revealed it was difficult to care for the resident with all the clutter and get around the narrow pathways in the room. Interview with RN #4/Unit Manager on 2/27/18 at 1:07 PM at the West Nurse's station revealed the staff was unable to keep a safe physical environment due to the refusal by the resident's family member. Interview with Environmental Services Technician #1 on 2/27/18 at 1:21 PM in the hall near room [ROOM NUMBER] revealed the resident's family member refused to allow staff to organize or clean the resident's room with cleaning supplies. Interview with the Administrator on 2/28/18 at 2:38 PM in her office confirmed the resident's room was not kept in a sanitary, orderly, and safe manner.",2020-09-01
248,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,657,D,1,1,TOUP11,"**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 # 285 of 39 Resident Care Plans reviewed. Findings include: Medical record review revealed Resident #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 12/4/17 revealed: Resident #285 was at risk for falls with interventions including: call light in reach and bed in lowest position while in bed, educate on call light use; resident able to return demonstration due to Dementia may need additional reminders, non-skid footwear on while up, and keep area free of clutter. Continued review of the careplan revealed an intervention dated 12/6/17: and on 12/7/17 fall mats to both sides of the bed. Medical record review of the Care Plan dated 12/4/17 revealed the resident to be at risk fo fall. Continued review revealed interventions were not revised after 12/17/17 fall. Interview with the Director of Nursing on 2/27/18 at 2:40 PM in the Director of Nursing office, confirmed the facility failed to update the care plan for Resident #285 after fall on 12/17/17.",2020-09-01
251,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,812,D,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility dietary department failed to dispose of expired food and failed to maintain dietary equipment in a sanitary manner in 2 of 6 observations. Findings include: Review of the facility policy Refrigerator and Freezer Storage, dated ,[DATE] revealed .Commercially prepared .Salad ( .pimento .) .Storage Time Manufacturer's expiration date or 7 days after opening (whichever comes first) .Special Instructions .date when opened and with use by date. Cheese .Storage Time Manufacturer's expiration date or best if used by date .Special Instructions .if removed from the original packaging, date with expiration date or best if used by date . Observation on [DATE] beginning at 8:59 AM in the dietary department with the Certified Dietary Manager (CDM) present revealed the walk-in refrigerator had a container of pimento cheese dated ,[DATE]. Interview with the CDM on [DATE] beginning at 8:59 AM in the dietary department walk-in refrigerator confirmed the pimento cheese was dated ,[DATE]. Further interview revealed when asked what the facility policy was regarding how long they keep opened food or leftovers, the CDM stated .throw out after 7 days . Observation on [DATE] beginning at 12:45 PM with Registered Dietitian (RD) #1 and the CDM present revealed 5 of 8 hood filters with greasy debris present, 5 of 6 protective glass hood light covers with an accumulation of debris on the interior and exterior of the cover. Further observation revealed the side splash guard of the grill had an accumulation of blackened debris. Interview with RD #1 and CDM on [DATE] beginning at 12:45 PM in the dietary department confirmed the dietary department failed to maintain the hood filters, hood light covers, and the side splash guard of the grill in a sanitary manner.",2020-09-01
252,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,908,D,0,1,TOUP11,"Based on observation and interview, the facility dietary department failed to maintain the hood lights in an operating condition in 2 of 6 observations. Findings include: Observation on 2/27/18 beginning at 12:45 PM and on 2/28/18 at 2:15 PM in the dietary department with Registered Dietitian (RD) #1 and the Certified Dietary Manager (CDM) present revealed 5 of 6 lights in the hood over the production equipment were not operating. Interview with RD #1 and the CDM on 2/27/18 beginning at 12:45 PM in the dietary department confirmed the facility failed to have the hood lights maintained in an operating condition.",2020-09-01
253,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2019-05-07,760,D,1,0,8UMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to administered the correct medications for 1 (#1) of 3 residents reviewed on 4/27/19 related to Licensed Practical Nurse #2 during the evening medication pass. The findings include: Review of the facility policy, Medication Administration--General Guidelines , effective 6/2016 revealed .medications are administered as prescribed in accordance with good nursing principles and practices .the five rights are applied for each medication being administered . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment Medical record review of a comprehensive care plan revised 4/9/19 revealed Resident #1 was monitored and assessed for functional potential, mobility and generalized weakness. Medical record review of the Physician's orders revealed medications given in error to Resident #1 included: Keflex for infection; [MEDICATION NAME] to relax the muscles; Requip for [MEDICAL CONDITION] or Restless Leg Syndrome; [MEDICATION NAME] for Constipation, [MEDICATION NAME] for Benign [MEDICAL CONDITION] of the Prostate; and [MEDICATION NAME] for depression and [MEDICAL CONDITION]. Medical record review of the SBAR (Situation, Background, Appearance, Review/Notify) form dated 4/27/19 revealed a med error occurred. Medical record review of a transfer form from the facility to the hospital dated 4/27/19 revealed the key reason for transfer was a possible allergic reaction with the primary reason for transfer being diagnostic testing, not admission. Continued review revealed a medication error involving Resident #1 had occurred. Interview with the Director of Nursing on 5/6/19 at 9:00 AM in the conference room confirmed LPN #2 made a medication error by administering the wrong medications to Resident #1 on 4/27/19 during the evening medication pass. Interview with the Nurse Practioner on 5/6/19 at 11:40 AM in the conference room confirmed LPN #2 gave Resident #1 the wrong medication on 4/27/19 during the evening medication pass.",2020-09-01
254,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2020-01-08,761,D,0,1,OQRZ11,"**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 stored and secured in 1 of 7 (C Hall Medication Cart) medication storage areas. The findings include: 1. The facility policy titled, MEDICATION STORAGE IN THE FACILITY, dated 6/2016 documented, .Medication rooms, carts, and medications supplies are locked when not attended by persons with authorized access . 2. Observation in the C Hall outside of room [ROOM NUMBER] on 1/7/20 at 4:20 PM, showed an unlocked and unattended medication cart. During an interview conducted on 1/8/20 at 7:50 AM, the Director of Nursing (DON) was asked if a medication cart should be left unlocked and unattended. The DON stated, No.",2020-09-01
256,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2020-02-05,880,D,0,1,8DF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview the facility failed to follow infection control practices for 2 residents (#34 and #125) of 3 residents in isolation precautions of 18 sampled residents. The findings include: Review of the facility policy Transmission-Based Procedures revised date 11-2019 showed .Enhanced Barrier Precautions .In addition to Standard Precautions, use Enhanced Barrier Precautions (EBP) during high-contact patient care activities .EBP expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated .Equipment .Appropriate Contact Precautions sign on door . Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care dated 1/31/2020 showed .enhanced barrier percation (precaution) in place . Review of the physician's order dated 2/1/2020 showed .enhanced barrier precautions r/t (related to) ESBL (Extended Spectrum Beta-Lactamase) in the urine . Observation on 2/3/2020 at 11:40 AM, on the 400 hall, showed no isolation sign on Resident #34's door to indicate the resident was in isolation. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/2020 at 11:40 AM, on the 400 hall, confirmed that Resident #34 was on enhanced barrier precautions for ESBL in the urine and an isolation sign had not been posted on the resident's door. Record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care revised date 2/3/2020 showed .pt (patient) on enhanced barrier precautions related to lice on scalp . Observation on 2/3/2020 at 9:30 AM, on the 100 hall, showed no isolation sign on Resident #125's door to indicate the resident was in isolation. This surveyor entered the resident's room and was thereafter verbally informed by a staff member that an isolation room had been entered. Interview with LPN #1 on 2/3/2020 at 11:35 AM, on the 100 hall, confirmed the resident was on isolation for head lice and an isolation sign had not been posted on Resident #125's door. Interview with the Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room, confirmed the facility had not posted isolation signs for Residents #34 and #125.",2020-09-01
257,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2019-02-06,756,D,0,1,JQRT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide a rationale in response to pharmacy recommendations for 1 resident (#53) of 5 residents reviewed for unnecessary medications, of 36 sampled residents. The findings include: Review of the facility policy Consultant Pharmacist Reports, dated 6/2016, revealed .Recommendations are acted upon and documented by .the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Medical record review revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's quarterly Minimum (MDS) data set [DATE] revealed Resident #53 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 7/23/18 revealed .Patient has continued on current dose of [MEDICATION NAME] (a medication used to treat anxiety) since 4/2018. Please evaluate risks vs (versus) benefits of current dose and consider reduction. If a reduction is not indicated, please document reasoning below .Recommend: Discontinue [MEDICATION NAME] 7.5 mg (milligrams) bid (twice daily). Start [MEDICATION NAME] 3.75 mg po (by mouth) qam (every morning) and 7.5 mg po qpm (every evening) . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale read .DO NOT D/C (discontinue) . Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 8/17/18 revealed .Consider drawling labs to evaluate benefits vs risks of [MEDICATION NAME] (a medication used to treat high cholestral) in this patient .Recommend: Order lipid panel and liver function tests . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale was left blank. Interview with Assistant Director of Nursing on 2/06/19 at 7:35 AM, in the conference room, confirmed .They don't always fill out the form . Continued interview confirmed the facility failed to obtain a Physician's rationale in response to the Pharmacist's recommendations dated 7/23/18 and 8/17/18.",2020-09-01
259,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-05-01,609,D,1,0,22N711,"**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 interview, the facility failed to report an allegation of abuse within 2 hours to the State Survey Agency for 1 resident (#4) of 3 residents sampled for abuse, of five sampled residents. The findings included: Review of facility policy, Abuse, (undated) revealed .if you have reasonable suspicion that a crime has occurred against a resident .Federal Law Requires that you report your suspicion directly to .the State Survey Agency . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of a Nursing Note dated 3/26/19 at 10:00 PM revealed .Pt (patient) A&O (alert and oriented) .some confusions (at) times . Medical record review of a Nursing Note dated 4/11/19 at 4:00 AM revealed .went to check on pt .not responding in usual manner .very lethargy .speech sluggish . Continued review revealed the resident was transferred to a local hospital with altered mental status and a urinary tract infection [MEDICAL CONDITION]. Review of the facility investigation dated 4/24/19 revealed a caseworker with Adult Protective Services (APS) contacted the facility on 4/24/19 and advised them while Resident #4 was in the hospital the resident alleged she was sexually abused by an unidentified male staff member at the facility sometime prior to her hospitalization on [DATE]. Further review revealed the facility did not report the allegation to the State Survey Agency. Interview with the Director of Nursing and the Risk Manger on 4/30/19 at 6:00 PM, in the conference room, confirmed the facility failed to report an allegation of abuse to the State Agency within 2 hours of notification of the allegation. In summary, the facility was aware of an allegation of abuse on 4/24/19 and as of 4/30/19, the facility had not reported the allegation of abuse to the State Survey Agency (7 days).",2020-09-01
260,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-07-26,225,D,1,0,RMD011,"**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 interview, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency for 1 resident (#5) of 3 residents reviewed for abuse of 5 sampled residents. The findings include: Review of the facility policy Abuse dated 11/2016 revealed .The facility must ensure that all alleged violations involving mistreatment, neglect, exploitation, mistreatment, misappropriation of resident property or abuse .are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Brief Interview for Mental Status (BIMS) dated 5/22/17 revealed Resident #5 was severely cognitively impaired. Medical record review of a psychiatric progress note dated 6/6/17 revealed Resident #5 was reported to have periods of extreme agitation and was noted to show a significant overall decline, altered mental status, and was unable to focus. Review of a facility investigation dated 6/12/17 revealed the granddaughter of Resident #5 reported to the Assistant Director of Nursing (ADON) during a visit her grandmother stated a partner at the facility had slapped her. Continued review revealed Resident #5 could not identify the partner nor could she state when the alleged incident occurred. Further review revealed the resident did not report the alleged incident until the granddaughter told the resident .tell .about the lady that slapped you from here . Continued review revealed Resident #5 stated a woman had slapped her in the face when she was at the beauty shop and the person had short and long hair. Further review revealed the resident stated the incident happened a few days ago .down on .old highway .at the building with bricks .beauty shop . Continued review revealed the Risk Manager informed the granddaughter a complete investigation would be conducted and she (Risk Manager) would notify the police, but the granddaughter stated .No I am going to take her so it will not alert anyone . Interview with the Risk Manager on 7/26/17 at 10:00 AM, in Conference room [ROOM NUMBER], confirmed an allegation of abuse involving Resident #5 was reported to the facility on [DATE] and the facility failed to report the allegation to the state survey agency timely.",2020-09-01
262,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,645,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#90) identified with a possible serious mental disorder to the state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) of 6 residents reviewed for PASARR of 37 sampled residents. The findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Medical record review of a PASARR Level I assessment dated [DATE] revealed the resident had no [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Evaluation dated 3/11/19 revealed .Worsening depression .she reports the increase of [MEDICATION NAME] (medication to treat depression) did not help .she does admit to a history of mood swings and thinks she may have [MEDICAL CONDITION] (a psychiatric disorder) .Diagnosis .[MEDICAL CONDITION] 1 Disorder . Interview with the Minimum Data Set (MDS) Coordinator on 7/30/19 at 1:39 PM, in the conference room, confirmed the facility failed to refer Resident #90 to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services after her [DIAGNOSES REDACTED].",2020-09-01
263,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,656,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a comprehensive care plan for pain management for 1 resident (#266) of 3 residents reviewed for pain of 37 residents sampled. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered . Medical record review of a Quarterly 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 frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the comprehensive care plan had not been implemented to provide pain medications as ordered for Resident #266.",2020-09-01
264,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,697,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure pain medication was administered timely resulting in an increase in pain for 1 resident (#266) of 3 residents reviewed for pain of 37 sampled residents. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed, .Medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed, . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .monitor for break-through pain .monitor and document response to pain meds .administer prescribed pain medication as needed/ordered to maintain patient comfort level .perform ongoing pain assessments to determine if the pain management regimen is meeting the patient's pain relief goal . Medical record review of a Quarterly 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 frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible). Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed, .my normal pain level is about 7 or 8 . Further interview revealed when the 9:00 PM meds are late .oh it may be a 10 by then .it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, confirmed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's pain medications in a timely manner resulting in an increase in pain for Resident #266.",2020-09-01
265,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,725,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's Assignment Sheets, review of the facility's Midnight Census Reports, resident interviews, and staff interviews, the facility failed to maintain adequate staffing levels to ensure timely administration of medications for 1 resident (#266) residing on 1 unit (2 East) of 10 units observed. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly 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 frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Review of the Facility's Midnight Census Reports dated 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/16/19, 7/18/19 revealed a resident census of 53 for the 2 East Unit. Review of the Facility's assignment sheets dated 7/1/9, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/18/19 revealed one LPN on duty on the 2 East Unit for the 7:00 PM to 7:00 AM shift. Further review of the Facility's assignment sheet dated 7/16/19 revealed one LPN on duty on the 2 East Unit for 7:00 AM to 7:00 PM shift until 9:00 AM when another nurse came on duty. Continued review of the facility assignment sheet dated 7/23/19 revealed one LPN on duty on the 2 East Unit from 3:00 PM to 5:30 PM. Further review of the facility assignment sheet dated 7/24/19 revealed on LPN on duty on the 2 East Unit for the 7:00 AM to 7:00 PM shift. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with Licensed Practical Nurse (LPN) #7 on 7/28/19 at 3:50 PM, at the 2 East nurse's station, revealed she had been .pulled to another floor . on 7/23/19 and 7/24/19 leaving one nurse on the 2 East Unit. Interview with LPN #3 on 7/28/19 at 3:56 PM, at the 2 East nurse's station, revealed she works the 7:00 AM to 7:00 PM shift. Further interview revealed nurses are frequently .pulled to another floor .leaving one nurse to care for 53 residents . Continued interview revealed the last time this occurred was on 7/23/19 and 7/24/19. Interview and observation of the assignment sheets dated 7/23/19 and 7/24/19 with the Director of Nursing (DON) on 7/29/19 at 2:16 PM, in conference room A, revealed the facility's goal for staffing for the 2 East Unit was to have two LPNs on staff for the 7:00 AM to 7:00 PM shift. Further interview confirmed on 7/23/19 one LPN had been on duty from 3:00 PM until 7:00 PM due to the other LPN had been pulled to cover the 3 East Unit leaving one nurse to provide care for 53 residents. Continued interview confirmed one LPN had been on duty on the 2 East Unit on 7/24/19 for the entire shift of 7:00 AM to 7:00 PM to provide care for 53 residents. Interview with the 2 East Unit Manager on 7/29/19 at 3:39 PM, in the Unit Manager's office, revealed medications are frequently administered late when there is one nurse on duty. Further interview revealed the Unit Manager would do all of the charting, take phones calls, and take physician orders [REDACTED]. Continued interview revealed the Unit Manager works 5 days a week and the LPN on duty would have to administer medications, chart, take phone calls, and take physician orders [REDACTED]. Interview with the DON on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with LPN #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM to 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with LPN #4 on 7/30/19 at 7:23 AM, on the 2 East hallway, revealed the medications are sometimes administered late .that happens .sometimes I'm just busy with other things Continued interview revealed it was difficult to get the medications administered on time when there is one nurse on duty. Interview with LPN #5 on 7/30/19 at 7:27 AM, on the 2 East hallway, revealed medications are to be administered .1 hour before or 1 hour after the scheduled time. Further interview revealed it was difficult to administer meds on time when there was one LPN on duty .we have 52 to 53 patients . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with LPN #5 on 7/30/19 at 9:21 AM, on the 2 East hallway, revealed Resident #266's 5:00 PM medications had been administered at 7:41 PM on 7/16/19 .that's the day my partner (LPN #4) called in . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview and observation of the 2 East Unit with Certified Nursing Assistant (CNA) #2 on 7/30/19 at 10:05 PM, on the 2 East hallway, revealed no nurse was on the unit. Continued interview with CNA #2 revealed the night shift nurse had called in and the Shift Supervisor had been covering the unit but was not currently on the floor. Interview with LPN #6 on 7/30/19 at 10:10 PM, at the 2 East nurse's station, revealed she had just arrived to the unit. Further interview revealed she had been called to come in to work at 11:00 PM due to the nurse who had been scheduled for the 7:00 PM to 7:00 AM shift had called in. Interview with the Shift Supervisor on 7/30/19 at 10:12 PM, at the 2 East nurse's station, revealed she had been on another unit assisting with a pharmacy delivery but was the nurse responsible for the 2 East Unit until another nurse arrived. Continued interview revealed the night shift nurse had called in. Further interview revealed the day shift nurses had stayed over to administer the 9:00 PM medications. Continued interview revealed the Shift Supervisor had been covering the 2 East Unit with a census of 53 residents from 9:30 PM until another nurse arrived at 10:00 PM but had also been assisting with the other units in that building and had not been on the 2 East Unit the entire time. Interview and observation of the Assignment sheets, Midnight Census Reports, and Administration Log Reports with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed Resident #266's 9:00 PM medications had not been administered timely on 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, and 7/18/19. Continued interview confirmed there had been 1 LPN on duty for the 7:00 PM to 7:00 AM shift with a resident census of 53 for these dates. Further interview confirmed Resident #266's 5:00 PM medications had not been administered timely on 7/16/19. Continued interview confirmed 2 LPN's had been scheduled to work the 7:00 AM to 7:00 PM shift on 7/16/19 but one of the LPN's had called in with a resident census of 53. Further interview confirmed the facility failed to provide adequate staffing to provide timely administration of Resident #266's medications.",2020-09-01
266,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,760,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#266) was free from significant medication errors of 7 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed .Medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly 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 frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often given late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock meds (medications) until 11:30 at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain .if I don't ask for them at 8:30 (PM) or 9:00 (PM) then I may have to wait and then I'm in pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's medications timely.",2020-09-01
267,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2018-08-01,761,D,0,1,DS1Q11,"Based on review of facility policy, observation and staff interview, the facility failed to ensure all medications had been labeled with a correct expiration date for 8 bags of medication, in 1 of 10 medication storage rooms observed. The findings include: Review of the facility policy Medication Ordering, Receiving and Storage revealed .The FDA (Food and Drug Administration) requires an expiration date on all medications . Observation with the facility Risk Manager on 8/1/18 at 8:40 AM, in the 300 hall medication room, revealed 8 reconstituted 100 ml (milliliter) bags of Tazicef (antibiotic) 1 gram available for use. Continued observation revealed the 8 bags of antibiotics delivered on 7/30/18 had an expiration date of 7/30/18. Interview with the facility Pharmacist on 8/1/18 at 10:01 AM, in the conference room, confirmed the facility failed to ensure the policy for medication storage was followed by not ensuring the bags of antibiotics were labeled correctly.",2020-09-01
268,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-10-11,323,D,1,0,19XQ11,"**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 ensure fall interventions were in place for 1 resident (#3) of 4 residents reviewed for falls. The findings included: Review of the facility's policy, Falls Prevention, revised dated 9/25/14, revealed .3. Interventions .d. implement appropriate interventions immediately . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the post fall assessment dated [DATE], at 7:45 AM, revealed staff responding to alarm sounding. Resident was found on the floor with wheelchair tipped, supine position. Resident reports that he was trying to get back in bed. Head to toe assessment negative for obvious deformity or injury at this time. However, he does c/o (complain) pain in back, his hips, and a headache. ROM (range of motion) NCB (no change base line) .Interventions .assess for need for anti-tip bars for w/c(wheelchair), add sensor pad to w/c . Review of the care plan updated on 9/11/17, revealed the new intervention for falls was the sensor pad alarm to the w/c. Observation on 10/9/17, at 2:20 PM, in the room of Resident #3, revealed the sensor pad alarm was not in the resident's wheelchair. Interview with a Licensed Practical Nurse (LPN) #1 at the time of observation confirmed the sensor pad alarm was not in the resident's wheelchair. Continued interview with the LPN confirmed the sensor pad alarm was to be in place as part of the falls intervention.",2020-09-01
269,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2018-10-17,580,D,1,0,RHRF11,"**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 interview, the facility failed to immediately report a fall to the supervising nurse and failed to immediately report a fall with injury to the responsible party for 1 Resident (#1) of 8 residents reviewed for falls, of 10 sampled residents on 1 of 11 nursing units observed. The findings included: Review of the facility policy Resident Condition Change Notification (revised 1/7/2010) revealed .an acute patient status change .are reported to the medical staff immediately .resident .patient representative are to be notified when there is a patient status change .resident's condition, medical staff notification and orders .interventions .effectiveness .patient .or patient representative notification is documented . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact); had no symptoms of [MEDICAL CONDITION]; had limited range of motion in the upper and lower extremities; had urinary and fecal incontinence; was non-ambulatory; and was dependent on staff with maximum assistance of one person for all activities of daily living. Continued review revealed Resident #1 had a history of [REDACTED]. Review of the facility investigation dated 10/11/18 at 5:45 AM revealed during incontinence care Certified Nurse Aide (CNA) #1 ran out of supplies and left the resident lying on her back on the bed while she went to retrieve more supplies from outside the room. Continued review revealed when CNA #1 returned to the room to (2 minutes later) she observed Resident #1 seated on the floor, to the right side of the bed, with her back against the bedframe. Further review of the investigation revealed CNA #1 did not immediately notify her supervising nurse when she found Resident #1 in the floor, but instead summoned a co-worker (CNA #2) to assist her with lifting Resident #1 back onto the bed. Continued review revealed neither CNA #1 nor CNA #2 reported the resident's fall to the supervising nurse or to the off-going or oncoming nurse or oncoming CNA during the shift report. Further review revealed Resident #1 exhibited symptoms of swelling and skin discoloration to the right leg on 10/11/18 around 4:45 PM (approximately 11 hours later). Continued review revealed Licensed Practical Nurse (LPN) #1 did not notify the responsible party for Resident #1 of the resident's change in condition until 10/12/18 around 7:00 AM (12 hours after the swelling and discoloration was noted). Telephone interview with CNA #1 on 10/16/18 at 8:15 PM confirmed the CNA did not immediately report finding Resident #1 on the floor to her supervising nurse or to the oncoming nurse or oncoming CN[NAME] Further interview confirmed CNA #1 failed to follow facility policy. Telephone interview with LPN #1 on 10/17/18 at 10:05 AM revealed she was first aware of Resident #1's change in condition on 10/11/18 at 4:45 PM and was unaware the resident had fallen earlier that day. Continued interview confirmed LPN #1 failed to notify the resident's responsible party of the change in condition until the following morning (12 hours after the change in condition had been identified and treatment initiated). Interview with the Director of Nursing (DON) and the Risk Manager on 10/17/18 at 5:05 PM, in the conference room, confirmed the facility failed to follow facility policy, failed to notify Resident #1's responsible party of the change in the condition, and failed to report Resident #1's fall to the supervising nurse.",2020-09-01
270,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-12-16,580,D,1,0,DCNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to notify the responsible party of a fall for 1 resident (#2) of 3 residents reviewed for change in condition. The findings included: Review of the facility policy, Resident Condition Change Notification, last revised 11/2016, revealed .The medical staff .and .patient (resident) representative are to be notified when there is a patient status change . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a facility fall investigation dated 11/21/19 revealed Resident #2 fell on [DATE] at approximately 4:00 AM. Review of a facility document dated 11/23/19 revealed the responsible party for Resident #2 was not notified of the fall until 11/23/19 at approximately 6:30 PM (2days after the fall). Interview with the Director of Nursing on 12/16/19 at 7:15 PM, in the conference room, confirmed the facility failed to notify the responsible party for Resident #2 of the resident's fall on 11/21/19. Further interview confirmed the responsible party was not notified until 11/23/19 (2 days later) and the facility failed to follow facility policy.",2020-09-01
271,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2018-03-14,725,D,0,1,6Z4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility staffing schedules and interview, the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3/11/18 for 1 floor (5th) of 4 floors reviewed. Findings include: Record review of the facility staffing for 3/11/18 revealed 4 Certified Nurse Aides (CNAs) were scheduled for the 7:00 PM to 11:00 PM shift with 56 residents on the 5th floor. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15/15, (cognitively intact), and required total 1 person assistance for toileting. Interview with Resident #63 on 3/12/18 at 8:29 AM in the resident's room on the fifth floor revealed .they are not answering the call light .takes 40-45 minutes to answer and I can't hold it and wet myself . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #54 had a BIMS score of 13/15, (cognitively intact), and required 2 person assistance for bed mobility and transfers. Interview with Resident #54 on 3/13/18 between 2:10 PM and 2:50 PM during the Resident Council interviews in the Cafe revealed .this pass weekend I had to wait to be put in bed .I usually go to bed between 8:00 PM - 9:00 PM but I had to wait and was put to bed between 10:00 PM - 11:00 PM . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #5 had a BIMS score of 13 (cognitively intact). The resident needed extensive assist with 1 person for bed mobility, total dependent with 2 persons for transfer. Interview with Resident #5 on 3/12/18 at 2:48 PM in the resident's room revealed .last night I did not get to bed until 11:00 PM and was told by the tech (CNA) she had many other people that needed same care I did .I normally get to bed 9:00 PM-9:30 PM . Interview with CNA #3 on 3/14/18 at 6:00 PM on the 5th floor revealed they had 4 CNAs on each shift for the week-end. Further interview revealed if they are giving showers or taking care of other residents then the residents had to wait until they are finished to get care. Interview with CNA #2 on 3/14/18 at 5:45 PM on the 5th floor revealed she worked this past week-end and they had 4 CNAs on the floor for the 7:00 PM -11:00 PM shift. Further interview revealed on 3/11/18 on the 7:00 PM-11:00 PM shift Resident #5 had to wait 45 minutes to be put to bed because CNA #2 and another CNA were assisting 2 other residents at the time and couldn't put her to bed as she requested. Continued interview confirmed Resident #5 had to wait 45 minutes to be put to bed and the facility failed to provide adequate staffing to meet the needs of the resident.",2020-09-01
272,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2018-03-14,921,D,0,1,6Z4211,"Based on facility policy review, observation and interview, the facility failed to maintain a clean environment for 1 of 5 observed fans on the 5th floor. Findings include: Review of the facility policy Infection Control Standard Precautions effective date 11/1/07 revealed .Environmental Control .Ensure that environmental equipment and other frequently touched surfaces are appropriately cleaned . Observation on 3/12/18 at 3:12 PM in the room of Resident # 5 revealed a table top fan on the bed side table in operation and directed at the resident seated in power wheelchair. Further observation revealed the fan grate had a heavy accumulation of hanging debris. Interview with Assistant Director of Nursing #2 on 3/12/18 at 3:19 PM in Resident #5's room confirmed the fan was dirty and was directed toward the resident.",2020-09-01
273,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-04-10,550,D,0,1,TZD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to respectfully address 1 resident (#212) out of 45 residents requiring feeding assistance, referred to as a feeder. The findings include: Facility policy review, Quality of Life-Dignity, dated 2001 and revised 2009, revealed .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Medical record review revealed Resident #212 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #212's Quarterly Minimum Data Set ((MDS) dated [DATE], the Significant Change MDS dated [DATE], and the Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Further record review of the MDS revealed the resident required extensive assistance for Activities of Daily Living (ADL's) including total dependence for eating. Medical record review of Resident #212's Care Plan (Nutrition) dated 3/26/19 revealed .Assist with meals as needed . Medical record review of Resident #212's Certified Nurse Technician (CNT) Notes dated 3/1/19-4/10/19 revealed .Eating: Total Dependence-full staff performance every time . Interview with Resident #212 on 4/8/19 at 9:30 AM in the room revealed resident has heard staff calling resident and other residents a feeder and has to wait to be fed last. Further interview revealed that multiple staff members have told her that the trays on the hall are passed first to residents who can feed themselves and then they bring the trays up for the feeders. Continued interview on 4/9/19 at 8:30 AM stated the resident has heard the CNT's talking in the hallway and in the resident's room referring to residents when trays are being passed as feeders. Examples given by resident were .who's got this feeder? .who's the next feeder? . Interview with CNT #1 on 4/10/19 at 4:30 PM in the 3rd floor hallway when asked how feeding assistance for residents was coordinated at mealtimes revealed .there are 9 feeders on the floor .they're (CNT's) assigned based on how long it takes the feeders to eat .usually the first cart is delivered to the floor for the self-feeders and then the 2nd cart has the feeders trays . Interview with Registered Nurse (RN) #1, identified as the facility Staff Educator in charge of training Paid Feeding Assistants and CNT's, on 4/10/19 at 4:35 PM in her office, confirmed .We (our facility) teach all staff to refer to residents as total assist or monitored assistance for feeding . Interview with the Administrator on 4/10/19 at 4:38 PM in the facility lobby confirmed residents requiring assistance for eating should be referred to as .total assistance for feeding or total assist diners. Interview with the Director of Nursing on 4/10/19 at 5:50 PM in the facility dining room confirmed .I expect all staff to refer to residents that require total assistance for feeding as total assist diners.",2020-09-01
274,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-04-10,689,D,1,1,TZD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to investigate an incident which involved a non-facility [MEDICATION NAME] syringe for 1 resident (#13) of 69 reviewed. The findings include: Review of the facility policy Accidents/Incidents Investigations dated 10/7/17 revealed .An investigation of the accident/incident will be made by the designated staff person . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Medical record review of the physician orders dated 2/16/19 revealed .Urine Drug Screen . Continued review revealed no orders for [MEDICATION NAME]. Medical record review of the Urine Drug Screen dated 2/16/19 revealed .[MEDICATION NAME] Positive . Medical record review of the physician progress notes [REDACTED].Pt (patient) seen at administrator's request regarding recent + (positive) drug test for [MEDICATION NAME] after finding a syringe in pts bed. Pt continues to deny any drug use, but has a long history of drug dependence and addiction and agrees that (pt) needs drug rehabilitation and treatment for [REDACTED]. Review of the facility investigation revealed no investigation addressing the incident for Resident #13. Observation on 4/8/19 at 9:46 AM in Resident #13's room revealed the resident in bed eating breakfast and appeared very slow to respond and sluggish in movement. Interview with Resident #13 on 4/8/19 at 4:03 PM in Resident #13's room revealed .I just got [MEDICAL CONDITION]. I looked at it (syringe) and the nurse said I had it in my arm. I did not have any blood on me. I found the needle it was up under one of those boxes and I picked it up and looked at it. I never stuck that in my arm ever. It was up under the box and it looked like it was opened and not closed very well . Continued interview revealed .she (nurse) said what in the world are you doing, are you sticking that in your arm? I told her I was just looking at it and was going to give it back to her. I was cleaning in the box . Interview with the Administrator on 4/9/19 at 2:02 PM confirmed the [MEDICATION NAME]- needle did not belong to the facility. Continued interview revealed .It was not our needle. We did not leave it in there at all . Interview with Licensed Practical Nurse (LPN) #1 on 4/9/19 at 2:17 PM in the conference room revealed, LPN #1 was the weekend supervisor on the alleged date of the incident. Continued interview with LPN #1 when asked if a facility report was completed confirmed .I just wrote it on a piece of paper and placed it in a file. I did not feel it was appropriate to place it in the resident record . Interview with the Administrator 4/10/19 at 6:10 PM in her office confirmed, the [MEDICATION NAME] needle was found in Resident #13's room. Continued interview confirmed the facility failed to investigate an incident which involved a non facility [MEDICATION NAME] needle. Continued interview revealed .we need to make sure we are documenting everything we do .",2020-09-01
275,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,609,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility document review, medical record review, and interview, the facility failed to report an incident of misappropriation of resident property to the appropriate agency within the prescribed time frame. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
276,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,610,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, medical record review, and interview the facility failed to conduct a thorough investigation of an alleged misappropriation of resident property. The findings included: Review of facility policy, Abuse Prevention, revised 3/27/13, revealed .The facility has a zero tolerance for abuse .The resident will not be subjected to mistreatment, neglect, or misappropriation of property .A criminal background check shall be initiated on any potential employee .All new employees will receive training on Abuse Prevention policies and procedures during the initial orientation period .Existing employees will receive ongoing training regarding Abuse Prevention .Employees who have been accused of resident abuse will be suspended from resident care duties until the investigation has been completed .An individual observing an incident of Resident abuse or suspected Resident abuse must immediately report the incident to their supervisor . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Review of a summary from the Administrator dated 8/15/19 revealed .Over the next few days we looked in her room and in laundry but could not find the money. She discharged home. I called to see if she had found it but she had not. I decided that I would help her out. I bought her a $350 VISA gift card and took it to her at her apartment. She declined the gift card and said she didn't know how to use it. I told her I would get her the cash. Her son came and picked it up today. I called her and she was very happy about being reimbursed . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
277,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2020-01-29,689,D,1,0,7MVB11,"**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 prevent an accident for 1 resident (Resident #1) of 3 sampled residents, resulting in the resident falling out of bed. The findings included: Review of the facility's policy titled Bed Bath, last revised 2/2018, showed .Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory problems and was severely impaired for daily decision making skills. The resident was incontinent of bowel and bladder and was totally dependent on staff for bed mobility and personal hygiene with 1 person assist. Review of a facility investigation dated 1/23/2020 showed Certified Nurse Assistant (CNA) #3 was giving Resident #1 a bed bath. When the CNA turned away from the resident to get a brief for the resident, the resident rolled out of the bed onto the floor. The resident had a hematoma on the right side of her head and scrapes on both knees and was sent to the Emergency Department (ED) for evaluation. The resident was discharged from the hospital to a different long term care facility on 1/28/2020. Review of a handwritten statement dated 1/23/2020 and signed by CNA #3 showed .I had turned her (Resident #1) over on her side then I was getting .brief .I turned back around her legs was (were) hanging off the bed. I tried to grab her but wasn't strong enough to pull her back .she rolled on the floor . During an interview on 1/28/2020 at 11:00 AM, Licensed Practical Nurse (LPN) #1 stated CNA #3 placed Resident #1 on her left side with her back to the CN[NAME] The CNA needed items that were placed behind her and when the CNA turned to obtain the needed items, the resident started to fall off of the bed. The CNA was unable to catch the resident; resulting in the resident falling on the floor.",2020-09-01
288,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,609,D,1,1,V5UN11,"**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 interview, the facility failed to ensure an alleged violation involving abuse was reported to the State Survey Agency within the required timeframe for 1 resident (#108) of 17 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention/Reporting Policy and Procedures, dated (YEAR), revealed .If the events that caused the allegation involve abuse and/or result in serious bodily injury, reporting must be within 2 hours of the allegation being made or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Certified Nursing Assistant Interdisciplinary Care Plan dated 1/15/19 revealed .Mood .short-tempered .Behavior Symptoms .physical behavioral symptoms directed at others . Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired. Review of a facility investigation dated 8/13/19 revealed Resident #108 was observed slapping another resident on 8/10/19 at 7:10 PM, in the secure unit. Further review revealed the incident was reported to State Survey Agency on 8/12/19 at 11:44 AM (2 days later). Interview with the Director of Nursing on 8/21/19 at 7:51 AM, in the Conference Room revealed she was notified of an allegation of abuse late at night on 8/10/19. Further interview confirmed the allegation of abuse was not reported to the State Survey Agency until 8/12/19 at 11:44 AM. Continued interview confirmed the facility failed to report the allegation of abuse within the required time frame.",2020-09-01
289,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,755,D,0,1,V5UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to ensure expired medications were not available for resident use in 1 of 4 medication carts observed. The findings include: Review of the facility policy, Storage of Medication, revised 4/2007, revealed .Drugs and biologicals shall be stored in the packing, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers . Further review revealed .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . Observation with Licensed Practical Nurse (LPN) Unit Manager #1 on 8/21/19 at 3:20 PM, at the 300 lower end medication cart, in the 300 hallway revealed the following expired items: 6 [MEDICATION NAME] (nausea medication) 4 milligram (mg) tablets, individually packaged with the expiration date of 8/3/19 in zip-lock bag labeled [MEDICATION NAME] 4mg with expiration label of 9/4/19. Further observation revealed 3 individually packaged [MEDICATION NAME] 4mg tablets with the expiration date of 9/4/19 were combined in the labeled zip lock bag. Interview with LPN Unit Manager #1 on 8/21/19 at 3:25 PM, at the 300 lower end medication cart, confirmed the expired 6 [MEDICATION NAME] 4mg tablets were available for resident use. Interview with the Director of Nursing (DON) on 8/21/19 at 4:05 PM, in the conference room, confirmed expired medications were available for resident use and the facility failed to discard of the expired medications per facility policy.",2020-09-01
292,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2017-09-27,315,D,0,1,L2NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medical justification, and obtain a physician's order for the use of [REDACTED] The findings included: Medical record review revealed Resident #194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #194 had an indwelling urinary catheter. Medical record review of Nurse's Notes dated 6/26/17 revealed .Resident has (urinary) catheter 18fr (French) .insertion date 6/22/17 . Medical record review of admission orders [REDACTED]. Medical record review of facility documentation revealed no order for Resident #194's urinary catheter. Medical record review of Urinary Continence Evaluation dated 6/26/17 revealed no documentation of medical justification for the use of the urinary catheter. Interview with the Director of Nursing (DON) on 9/27/17 at 9:40 AM, in the facility class room, confirmed .The physician does the orders on what hospital orders the resident comes with . Continued interview confirmed the facility did not require an order for [REDACTED].>Interview with the DON on 9/27/17 at 10:40 AM in the DON's office, confirmed .Don't need a cath (catheter) order like if a resident came with [MEDICAL CONDITION] would just follow those previous orders . Interview with the MDS Coordinator on 9/27/17 at 11:08 AM, in the facility classroom, confirmed an overactive bladder was not an indication for use of an urinary catheter based upon MDS guidelines. Interview with the Regional Quality Specialist on 9/27/17 at 11:15 AM, in the facility classroom, confirmed the facility failed to provide a medical justification for Resident #194's (urinary) catheter.",2020-09-01
293,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2017-09-27,431,D,0,1,L2NH11,"Based on review of facility policy, observation, and interview, the facility failed to separate medications and food in 1 of 3 medication refrigerators. The findings included: Review of the facility policy Storage of Medications, revised 4/2007, revealed .medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location . Medications must be stored separately from food and must be labeled accordingly . Observation with Licensed Practical Nurse #1 on 9/27/17 at 10:55 AM, in the 100 Medication Storage Room, revealed in the locked medication refrigerator, 2 cartons of liquid nutritional supplement, 1 bowl of pudding, and 1 large box of white wine. Further observation revealed medications including narcotics stored in the refrigerator. Interview with the Director of Nursing on 9/27/17 at 11:00 AM, in the Conference Room, confirmed the facility failed to store medications separately from food in the medication refrigerator.",2020-09-01
294,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,584,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide readily accessible soap products for 1 resident (#107), on 1 of 4 hallways observed, of 33 sampled residents. The findings include: Review of the facility policy Handwashing/Hand Hygiene, revised 8/2015, revealed .hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use .residents, family members and/or visitors will be encouraged to practice hand hygiene . Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 15, indicating the resident was cognitively intact, the resident was independent for ambulation and toileting, and performed hygiene with limited assistance. Observation on 10/9/18 at 8:15 AM, of the resident's room on the 400 hallway, revealed the soap dispenser above the sink did not have a cover and there was no soap in the dispenser. Continued observation revealed there was no soap or sanitizer at the sink. Interview with Resident #107 on 10/9/18 at 8:20 AM, in the Activity Room, confirmed the resident did not have soap to wash her hands at the sink in her room. Interview with the Director of Nursing and the Maintenance Director on 10/9/18 at 8:30 AM, in the resident's room on the 400 hallway, confirmed there was no cover for the soap dispenser and there was no soap available in the dispenser or next to the sink for the resident, staff, or visitors for handwashing. Continued interview confirmed the facility failed to have soap readily available for use in the resident's room.",2020-09-01
295,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,656,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement the plan of care for diabetic management for 1 resident (#96) of 33 residents sampled. The findings include: Medical record review revealed Resident #96 was admitted to the facility 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 14, indicating the resident was cognitively intact. Medical record review of the Care Plan dated 6/13/18 revealed .Potential for [DIAGNOSES REDACTED] (low blood sugar)/[MEDICAL CONDITION] (high blood sugar) secondary to [DIAGNOSES REDACTED].Administer medication as ordered . Medical record review of the physicians orders dated 6/6/18 revealed .sliding scale (amount of insulin given dependent on blood sugar result) over 450 (blood sugar result) give 12 units (of insulin) recheck (blood sugar) in 2 (hours) if still above 450 give 12 units Q (every) 2 (hours) until under 450 . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) R (regular) .Accuchecks (blood sugar check) BID (twice a day) .250-300/4 units (for blood sugar result of 250-300 give 4 units of insulin) 301-350/ 6 units 351-400/8 units 401- 450/10 units > (greater than) 450/12 units Recheck in 2 (hours) and repeat . Medical record review of the Diabetic Monitor Log dated 10/2018 revealed blood glucose levels were ordered for 6:30 AM and 4:30 PM. Continued review revealed blood glucose levels were greater than 450 on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18 at the 4:30 PM check, and there was no documentation of the blood glucose recheck in 2 hours or repeated insulin administration. Telephone interview with the hospice physician on 10/10/18 at 1:56 PM, confirmed it was her expectation the facility would recheck blood sugar and administer insulin coverage as ordered by the physician. Interview with the Director of Nursing (DON) on 10/10/18 at 2:40 PM, in the conference room, confirmed the facility failed to follow the physician's orders [REDACTED].#96's blood glucose and provide insulin coverage for blood glucose greater than 450.",2020-09-01
296,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,679,D,0,1,SM1F11,"**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 provide individual 1 on 1 activities for 1 resident (#72) of 33 residents reviewed. The findings include: Review of the facility policy Activities and Social Services, revised 12/2006, revealed .a resident .considered to lack sufficient decision making capacity, mental incompetence, or physical capacity to participate .the facility will provide activities . Medical record review revealed Resident #72 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan, Resident prefers to stay in door for activities, dated 6/1/18 revealed .provide one on one activities as indicated .continue to encourage outer room activity for social stimulation . Medical record review of the Record of One-to One Activities for Resident #72 revealed 6 entries of one-to-one activities from 3/1/18 to 7/22/18. Continued review revealed no further documentation of one-to-one activities. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 99, indicating severe cognitive impairment, and the functional status for ambulation, toileting, and hygiene was total dependence. Observations of Resident #72 on 10/8/18 and 10/9/18 throughout the day, revealed 1 occurrence of the resident being taken to a weight scale and then returned to the room. Continued observations revealed the resident in the private room with the blinds closed and the lights off over the 2 days observed. Interview with the Director of Nursing and the Activity Assistant on 10/9/18 at 5:00 PM, in the Conference Room, confirmed Resident #72 did not attend organized activities, was care planned for 1 on 1 activities, and no 1 on 1 activities were provided by the facility on 10/8/18 or 10/9/18. Interview with the Administrator on 10/9/18 at 5:35 PM, in the Conference Room, confirmed the facility had not provided 1 on 1 activities for Resident #72 since 7/22/18.",2020-09-01
297,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,755,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to timely order, obtain, and administer medications for 1 resident (#15) of 33 residents sampled. The findings include: Review of the facility policy Administering Medications, revised 12/2012, revealed .If a medication is ordered and not available from the pharmacy, the ordering physician or Nurse Practitioner/Physician Assistant should be notified for an alternative order until medication is available . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's orders dated 10/1/18-10/31/18 revealed .[MEDICATION NAME] (an antibiotic) .100 mg (milligrams) .Take 1 capsule by mouth once daily *Nurse to reorder* .(give at) 8 AM .Artificial tear drops instill 1 drop in right eye four times a day .(give at) 8 AM .12 PM .4 PM .8 PM . Medical record review of the Medication Record dated 10/1/18 -10/31/18 revealed [MEDICATION NAME] had not been given from 10/1/18 through 10/9/18. Further review revealed the artificial tears had not been administered on 10/9/18 for the 8:00 AM dose. Interview with Licensed Practical Nurse (LPN) #1 on 10/9/18 at 3:45 PM, in the nurses lounge/nurses station, confirmed the [MEDICATION NAME] and artificial tears were not available for administration. Continued interview confirmed the physician had not been notified of the unavailable medications. Interview with the Medical Director (the resident's physician) on 10/9/18 at 3:59 PM, at the 300 hall nurse's station, confirmed the Medical Director was unaware the artificial tears and [MEDICATION NAME] had been unavailable and was not administered to the resident. Continued interview revealed it was his expectation to be made aware of any missed doses of medication. Interview with the Director of Nursing (DON) on 10/10/18 at 2:38 PM, in the conference room, confirmed the facility failed to notify the Medical Director the [MEDICATION NAME] and artificial tears were unavailable for administration.",2020-09-01
298,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,756,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility pharmacy services failed to report irregularities to the physician for 1 resident (#96) of 3 residents reviewed for insulin administration of 33 residents reviewed. The findings include: Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physicians orders dated 6/6/18 revealed .sliding scale (amount of insulin given dependent on blood sugar result) over 450 (blood sugar result) give 12 units (of insulin) recheck (blood sugar) in 2 (hours) if still above 450 give 12 units Q (every) 2 (hours) until under 450 . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) R (regular) .Accuchecks (blood sugar check) BID (twice a day) .250-300/4 units (for blood sugar result of 250-300 give 4 units of insulin) 301-350/ 6 units 351-400/8 units 401- 450/10 units > (greater than) 450/12 units Recheck in 2 (hours) and repeat . Medical record review of the Diabetic Monitor Log dated 10/2018 revealed blood glucose levels were ordered for 6:30 AM and 4:30 PM. Continued review revealed blood glucose levels were greater than 450 on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18 at the 4:30 PM check, and there was no documentation of the blood glucose recheck in 2 hours or repeated insulin administration. Telephone interview with the hospice physician on 10/10/18 at 1:56 PM, confirmed it was her expectation the facility would recheck blood sugar and administer insulin coverage as ordered by the physician. Interview with the Consultant Pharmacist on 10/10/18 at 1:26 PM, in the Conference Room, confirmed it was his responsibility to review the charts monthly to ensure the physician's orders [REDACTED].#96 and the Consultant Pharmacist had failed to identify the irregularity during the monthly chart reviews.",2020-09-01
299,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,770,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory (lab) services as ordered by the physician for 1 resident (#46) of 33 residents sampled. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].LABS .TSH ([MEDICAL CONDITION] level), Lipid (cholesterol), CMP (Complete Metabolic Panel) yearly in (MONTH) .[MEDICATION NAME], CBC (Complete Blood Count), LFT (Liver Function Test), CRCL (Creatinine Clearance, a test for kidney function) , K+ (Potassium) every 6 months (May/Nov) . Medical record review of the lab results for Resident #46 revealed no documentation of a TSH, LIPID, CBC, or LFT level for (MONTH) (YEAR). Interview with the Director of Nursing (DON) on 10/11/18 at 10:14 AM, at the 200 hallway, confirmed the facility failed to obtain the labs for (MONTH) including the TSH, LIPID, CBC, and LFT.",2020-09-01
302,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,842,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to maintain an accurate and complete medical record of wound care treatment documentation for 1 Resident (#65) and for medication administration for 1 Resident (#96) of 33 residents sampled. The findings include: Review of the facility policy Wound Care, revised 10/2010, revealed .Documentation .The following information should be recorded in the resident's medical record .The date and time the wound care was given .If the resident refused the treatment and the reason(s) why .The signature and title of the person recording the data . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician/Prescriber Telephone Order dated 9/18/18 revealed .cleanse (right) gluteal abscess site (with) (wound cleanser), apply Dakins ([MEDICATION NAME] solution) 1/2 strength, wet to dry dressing bid (twice a day). Cover (with) [MEDICATION NAME] (type of foam dressing) . Review of the Treatment Record dated 9/1/18-9/30/18 revealed the treatment to the right gluteal abscess site had not been completed on the 2nd shift on 9/23/18, 9/26/18, and 9/28/18. Interview with the Wound Care Licensed Practical Nurse (LPN) on 10/10/18 at 2:57 PM, in the conference, room confirmed the treatment for [REDACTED]. Interview with the Director of Nursing on 10/11/18 at 9:05 AM, in the conference room, confirmed Resident #65's medical record was incomplete and the facility failed to follow the facility wound care policy. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 6/13/18 revealed .Potential for [DIAGNOSES REDACTED] (low blood sugar) /[MEDICAL CONDITION] (high blood sugar) secondary to [DIAGNOSES REDACTED].Administer medication as ordered . Medical record review of the Physicians Orders dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) .10 UNITS .ONCE DAILY . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed no documentation the resident received the [MEDICATION NAME] on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18. Interview with the Director of Nursing on 10/9/18 at 5:21 PM, at the 400 hall nurses station, confirmed the facility failed to document [MEDICATION NAME] administration on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18.",2020-09-01
303,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-11-27,569,D,1,0,GP5R11,"> Based on review of facility policy, review of resident funds accounts, and interviews, the facility failed to provide conveyance of personal funds within 30 days of discharge, transfer, or death for 4 residents (#5, #7, #8 and #9) of 39 residents reviewed for resident funds accounts. The findings included: Review of the facility policy Resident Refund Policy, last revised 3/20/17 revealed .To ensure that all resident accounts reconciled and maintained according to federal and state regulations .Any Resident refunds due shall be submitted, via email, with the appropriate documentation, to the Regional Field Controller (RFC) for approval . Review of resident funds accounts on 11/26/19 revealed the following: Resident #5 had $2631.50 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/6/19 (81 days earlier). Resident #7 had $497.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/16/19 (71 days earlier). Resident #8 had $175.75 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/25/19 (62 days earlier). Resident #9 had $40.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/29/19 (58 days earlier). Interview with the Administrator on 11/27/19 at 9:30 AM, in her office, revealed .it was brought to my attention in (MONTH) (2019) we (facility) had multiple outstanding past due refunds .contacted the Regional Director of Operations .to prevent a hardship on the corporation it was decided to pay a couple of the largest refunds monthly . Interview with the Business Office Manager on 11/27/19 at 9:45 AM, in the Administrator's office, revealed .I send a list of discharges to the corporate office at the end of each month . In summary, the facility failed to provide conveyance of resident funds within 30 days of discharge for Residents #5, #7, #8, and #9.",2020-09-01
304,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,684,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow Physician Orders for wound care and failed to follow Physician Orders for sliding scale insulin for 1 resident (#59) of 3 residents reviewed for wound care and sliding scale insulin. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician Telephone Order dated 12/16/2019, showed .Apply Z-guard (ointment to treat pressure wound) BID/PRN (twice daily and as needed) . Review of a Treatment Flow Sheet dated 12/1/2029-12/31/2019, showed Z-guard had been applied daily 12/16/2019-12/31/2019, and not BID/PRN as ordered. Review of a Treatment Flow Sheet dated 1/1/2020-1/31/2020, showed the Z-guard had been applied daily 1/1/2020, 1/2/2020, 1/3/2020 and 1/6/2020-1/21/2020. And not BID/PRN as ordered. The Z-guard had not been applied on 1/1/2020, 1/4/2020 and 1/5/2020 as ordered. Review of the Weekly Wound Assessment Sheet dated 12/16/2019, showed a sacrum stage II wound, onset 11/2019 measuring 1x (by)1 x 0.1 centimeter (cm). Review of the Weekly Wound Assessment Sheet dated 1/20/2020, showed the wound measured 1 x 1 x 0.1cm and did not increase in size. Observation of the resident on 1/22/19 at 1:30 PM, revealed the resident lying on her back with the head of bed elevated at 30 degrees and an air mattress in place. During an interview on 1/22/2020 at 4:00 PM, the Wound Nurse confirmed the wound care had been provided daily 12/16/2020-12/31/2020 and had been provided daily 1/2/2020, 1/3/2020, and 1/6/2020-1/21/2020. There was no documentation that wound care had been provided to Resident #59 as ordered. During an interview on 1/23/2020 at 8:20 AM, the Director of Nursing (DON) confirmed the facility failed to follow physician orders for wound care for Resident #59. Observation of Resident #59's wound on 1/23/2020 at 9:20 AM, with the Lead Supervisor showed an open area to the sacrum, pink wound bed, with no odor or drainage, and the area was blanchable (skin blanches with pressure). The resident was lying in the bed with an air mattress in place. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .[MEDICATION NAME] (medication to treat Diabetes) .BEFORE MEALS & (AND) AT BEDTIME .LOW DOSE SLIDING SCALE . Review of an Insulin Administration Documentation record dated 1/20/2020 8PM-1/23/2020 5AM showed the resident had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered for Resident #59. The Insulin Administration Documentation record showed the resident had a total of 8 incorrect doses of insulin administered from 1/20/2020-1/23/2020. During an interview on 1/23/2020 at 12:20 PM, the DON confirmed the facility failed to follow physician orders for sliding scale insulin for Resident #59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5:00PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale.",2020-09-01
306,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,760,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility policy review, medical record review, and interview, the facility failed to prevent a significant medication error for 1 resident (#59) of 3 residents reviewed for insulin administration. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .[MEDICATION NAME] (insulin medication to treat Diabetes) .BEFORE MEALS & (AND) AT BEDTIME .LOW DOSE SLIDING SCALE . Review of a blank Insulin Administration Documentation form undated showed: Low Dose Regimen (blood glucose ranges) - Less than 40= initiate [DIAGNOSES REDACTED] protocol and call MD (Medical Doctor) - 41-50= 0 units - 151-200= 0 units - 201-250= 3 units - 251-300= 4 units - 301-350= 6 units - 351-499= 9 units - Greater than 500= 12 units of insulin and call MD The Moderate Dose Regimen (blood glucose ranges) - Less than 40= initiate [DIAGNOSES REDACTED] protocol and call MD - 41-150= 0 units -151-200= 4 units - 201-250= 8 units - 251- 300= 10 units -301-350= 12 units - 351-499= 16 units - Greater than 500= 18 units and call MD Review of Resident #59's Insulin Administration Documentation form dated 1/20/2020 at 8PM-1/23/2020 5AM showed Resident #59 had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered. The form showed the following: - 1/20/2020 at 8PM, blood sugar 310, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 6 units as per ordered sliding scale. - 1/21/2020 at 5AM, blood sugar 245, [MEDICATION NAME] 8 units administered. The resident was to receive [MEDICATION NAME] 3 units as per ordered sliding scale. - 1/21/2020 at 8PM, blood sugar 267, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 4 units as per ordered sliding scale. - 1/22/2020 at 5AM, blood sugar 155, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. - 1/22/2020 at 12PM, blood sugar 197, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. - 1/22/2020 at 5PM, blood sugar 221, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 3 units as per ordered sliding scale. - 1/22/2020 at 9PM, blood sugar 251, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 4 units as per ordered sliding scale. - 1/23/2020 at 5AM, blood sugar 176, [MEDICATION NAME] 4 units administered, The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. A total of 8 wrong doses had been administered to Resident #59. The resident did not experience hypoglycemic episodes due to the incorrect doses being administered. During an interview on 1/23/2020 at 12:20 PM, the Director of Nursing confirmed the facility follows the Insulin Administration Documentation record for insulin low dose regimen. The DON confirmed Resident #59 had received 8 incorrect doses of insulin and the facility failed to follow physician orders [REDACTED].#59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5 PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale. The Physician stated there were no adverse side effects to the resident due to the incorrect insulin doses administered.",2020-09-01
307,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,842,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a physician had signed the Physician's Orders for Scope of Treatment (POST) (a physician's order which indicates end of life care preferences) for 1 (#46) of 24 sampled residents for POST forms. The findings include: Review of the medical record showed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Review of the Physician's Recapitulation Orders dated 1/2020 showed the resident had a Do Not Resuscitate (DNR) status. During an interview on 1/23/2020 at 8:30 AM, the Director of Nursing confirmed the POST dated 9/12/2019 had not been signed by a physician.",2020-09-01
308,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,880,D,0,1,5Y8I11,"**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 follow contact isolation precautions for 1 resident (#60) of 4 residents observed for contact isolation. The findings include: Review of the facility's policy titled, Isolation Policy, revised 4/5/2016, showed .Contact Precautions .Personal Protective Equipment .Wear gloves and gown when entering the room .a mini-stop sign will be placed outside the door . Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's Telephone Order dated 1/14/2020 showed contact precaution for Urinary Tract Infection [MEDICAL CONDITION] Multidrug Resistant Organism (MDRO). Observation at Resident #60's room on 1/21/2020 at 11:00 AM, showed a large metal box placed on the resident's entrance door with no signage on the door. During an interview on 1/21/2020 at 11:20 AM, Licensed Practical Nurse (LPN) #1 stated the resident was on contact isolation due to MDRO UTI. Observation on 1/21/2020 at 12:46 PM, showed LPN #1 entered the resident's room, donned gloves, and administered medication to Resident #60. Observation on 1/21/2020 at 12:48 PM, showed the Unit Secretary entered the resident's room without donning gloves or gown. During an interview on 1/21/2020 at 12:50 PM, the Unit Secretary stated she was not aware Resident #60 was on contact isolation .there is not a sign on the door . During an interview on 1/21/2020 at 12:55 PM, LPN #1 stated the staff had to don gloves prior to entering the resident's room and wear a gown if the staff came in contact with bodily fluids or .up close care . LPN #1 confirmed there was no contact isolation sign on Resident #60's door. Observation of the resident on 1/23/2020 at 9:40 AM, showed the resident sitting in a chair in her room with Certified Nursing Assistant (CNA) #1 present. Continued observation showed the staff member was not wearing a gown or gloves in the resident's room. During an interview on 1/23/2020 at 9:45 AM, with CNA #1 stated she had not applied gloves or gown prior to entering Resident #60's room, I know I should wear gloves but I was never told to wear a gown. During an interview on 1/23/2020 at 8:26 AM, the Director of Nursing confirmed the facility failed have contact isolation precautions in place for Resident #60 and failed to follow their facility policy.",2020-09-01
309,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-05-03,602,D,1,0,IO8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, observation, and interview, the facility failed to prevent misappropriation of a narcotic patch for 1 resident (#1) of 6 residents reviewed for misappropriation of property. The findings included: Review of the facility policy Abuse Prevention Program dated 8/17 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property .Protect our residents from abuse by anyone . Medical record review revealed Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the facility's investigation dated 4/8/18 at 5:30 PM, revealed Resident #1 called for LPN #2, and reported the other nurse had told her she was sent to change her pain patch. When LPN #2 checked the patch she discovered the pain patch missing but the [MEDICATION NAME] (clear dressing) was intact. When the facility was able to contact LPN #1 she stated she was trying to replace the torn [MEDICATION NAME] covering the patch, and accidently removed the patch with the torn [MEDICATION NAME]. She had discovered it in her scrub pocket late that night when doing laundry. On 4/9/18 at approximately 7:00 AM, LPN #1 reported to the Director of Nurses office, and was escorted to HR (Human Resources). At this time LPN #1 returned the patch to the facility. The facility noted the LPN had red eyes and unusual speech patterns. She was taken to the lab for a drug screen, which was failed due to urine failing to have a temperature with in the acceptable range. This was considered a positive and LPN #1 was terminated. Observation and interview with Resident #1 on 5/1/18 at 10:00 AM, in her room revealed on Sunday morning 4/8/18, LPN #1 was a new nurse her hair was blue, she asked me to stand up and I told her I couldn't. She said I'll have to put your pain patch on in the bed. I told her I didn't think it was time for it to be changed, but she said (LPN #2) said it was. She took off the old patch and folded it up in a small piece of gauze. Then she put something on my back, but when (LPN #1) checked she said she didn't put a new patch on. Interview with LPN #2 on 5/1/18 at 10:15 AM, on the 200 Central Hall revealed Resident #1 told her that girl told me you sent her in here to change my patch. I asked her if the girl had blue hair and she said yes that's her. I checked her patch. There was a [MEDICATION NAME] with the date and her (LPN #1's) initials but no patch. The old patch had been removed but she did not put on a new patch. Continued interview revealed somewhere between 9:45 AM, and 10:00 AM, she had observed LPN #1 flipping through my MAR (Medication Administration Record), and around 10:00 AM, (LPN #1) told me (Resident #4) wanted her 12:00 PM, pain pills and asked me if I had given them. She asked me if I wanted her to take the medicine to her and I told her no. Then about 11:30 AM, she told me (Resident #6) wanted a pain pill, and asked me if I wanted her to take it to him, again I told her no. Further interview revealed she had reported both incidents to the RN supervisor. She stated I went and told (RN #1) that she kept asking me if I wanted her to give my residents their pain medications. Interview with RN #1 on 5/1/18 at 12:10 PM, via telephone revealed, (LPN #2) came to me and said (Resident #1) had stated (LPN #1) had removed her patch. The [MEDICATION NAME] was there but there was not patch. It was dated and (LPN #1's) initials were on it. She identified her as the blue haired girl. (LPN #1) was working as a CNA (certified nurse aide) that day; she had no business in the MAR, or dealing with the medications. I told her to just be a CNA for today, and to forget about passing medication, just to do patient care. I had to redirect her a couple of times. She took the [MEDICATION NAME] (pain medication) patch off and kept it. Further interview revealed (LPN #1) had been complaining of being sick, and not long after she took the patch off, she said she was sick, and asked to leave and he had told her to go ahead and leave. Interview with LPN #1 on 5/1/18 4:30 PM, via telephone revealed When I took off the old [MEDICATION NAME], the patch must have come off with it. I reapplied the new [MEDICATION NAME] initialed and dated it. I didn't realize the patch was still on the old [MEDICATION NAME] until I found it in my scrub pocket. Further interview revealed LPN #1 stated as a CNA I should have reported to the nurse, but I am used to being the nurse and I had never worked as a CNA before. I didn't think anything about fixing the [MEDICATION NAME]. Review of facility documents, Daily Assignment Sheets for 3/29/18 through 4/8/18 revealed LPN #1 had worked as a CNA on 3/29, 3/30, 3/31, 4/1, 4/7 and 4/8/2018. Interview with CNA #2 on 5/2/18 at 8:45 AM, in the conference room revealed at approximately 2:00 PM, she (LPN #1) was in (Resident #1's) room, I walked down the hall, the resident's back was towards the door, and she (LPN #1) was standing at her back, as I walked by I heard her say (LPN #2) told me to come in and change your patch. Interview with the Administrator on 5/2/18 at 1:48 PM, in the conference room confirmed the facility failed to prevent misappropriation of a narcotic patch for Resident #1.",2020-09-01
310,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-09-07,609,D,1,0,OSU511,"> Based on review of the facility policy, facility investigation review, and interviews the facility failed to ensure staff report an allegation of abuse in a timely manner. The findings include: Review of the facility policy Abuse Investigation and Reporting dated 8/13/17, revealed .Reporting .2. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours . Review of afacility investigation dated 7/4/18, revealed while the facility was interviewing staff for an alleged allegation, CNA #4 made an allegation of abuse regarding CNA #3. During the interview CNA #4 revealed the allegation happened late (MONTH) or early June, and CNA #4 had not reported the allegation. Interview with the Director of Nursing (DON) on 9/4/18, at 10:40 AM, in the DON's office, confirmed CNA #4 had not reported the allegation of abuse regarding CNA #3 in a timely manner.",2020-09-01
311,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-12-05,686,D,0,1,2QW911,"**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 maintain infection control practices during a dressing change for 1 resident (#4) of 2 residents reviewed for pressure ulcers of 22 residents sampled. The findings include: Review of the facility policy Hand Washing With and Without Water Policy, revised 12/3/14 revealed, .Purpose .B. To reduce overall infection rates .I. Policy: [NAME] Handwashing will be utilized as a method of prevention and control of infection. Thorough handwashing is the most important factor in the control of infection. Handwashing should be done by clinical staff often when providing care. When hands are visibly dirty or contaminated wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water .B. If hands are not visibly soiled, use an alcholol- based .hand rub for routinely decontaminating hands. Handrubs should be used before care and after completion of care for each patient. C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur. Change gloves during patient care if moving from a contaminated body site to a clean body site .Procedure: A Indications for handwashing and antisepsis .1. Before giving direct care to patient; 2. After giving direct care to a patient .7 .after glove removal .9. After contact with body fluids or excretions, mucous membrames, non-intact skin, and wound dressings if hands are not visibly soiled .11. If moving from a contanimated body site to a clean body (site) during patient care . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident was severely cognitively impaired. Further review revealed the resident had a pressure ulcer. Observation of Resident #4's wound care with Registered Nurse (RN) #1 on 12/4/18 at 2:07 PM, in the resident's room, revealed RN #1 applied clean gloves and removed the soiled dressing from the resident's pressure wound. Further observation revealed the RN then removed the soiled gloves, and applied clean gloves without performing hand hygiene. Continued observation revealed RN #1 cleaned the wound, and without changing gloves and performing hand hygiene, picked up clean 4 x 4 (size of bandage) bandages, and applied wound cleanser to the clean 4 x 4 bandages with the contaminated gloves. Further observation revealed RN #1 removed the dirty gloves, and applied clean gloves without performing hand hygiene. Continued observation revealed the RN then used the 4 x 4 bandages the RN had wet with wound cleanser while wearing the dirty gloves, and packed the resident's wound with the contaminated 4 x 4 bandages. Further observation revealed RN #1 then removed the gloves worn while packing the pressure wound, did not perform hand hygiene, and applied a clean dressing with the bare hands. Interview with the Director of Nursing (DON) on 12/5/18 at 9:05 AM, in the conference room, confirmed it was the facility policy for nurses to perform hand hygiene between glove changes. Further interview confirmed it is the facility policy for the nurses to wear gloves with the application of a clean dressing. Continued interview confirmed RN #1 failed to maintain infection control practices during a dressing change.",2020-09-01
312,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-12-05,756,D,0,1,2QW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to act timely on pharmacy recommendations for 2 residents (#12 and #13) of 5 residents reviewed for unnecessary medications, of 22 residents reviewed. The findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a pharmacy recommendation dated 8/23/18 revealed .Drug, dosage and schedule presently on [MEDICATION NAME] (medication to treat depression) 50mg (milligrams) .(one tablet) HS (at bedtime) .tapered dosage and schedule [MEDICATION NAME] 25mg .(one tablet) HS (at bedtime) Further review revealed the Physician agreed with and signed the recommendation on 11/13/18 (sixty-six days later) and the order was not written and acted upon until 11/26/18 (seventy-nine days later). Interview with the Director of Nursing (DON) on 12/05/18 at 2:01 PM, in the conference room, confirmed the pharmacy recommendation had not been acted upon timely. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Pharmacy Recommendation dated 8/29/18 revealed .Drug, dosage and schedule presently on [MEDICATION NAME] (medication to treat depression) 20 mg daily tapered dosage and schedule [MEDICATION NAME] 10 mg daily . Continued review of the Pharmacy Recommendation revealed the Physician agreed with and signed the recommendation on 11/13/18 (sixty-six days later) and the physician's orders [REDACTED]. Interview with the DON on 12/5/18 at 2:01 PM, in the conference room, confirmed the Pharmacy Recommendation was not acted upon timely.",2020-09-01
313,"NHC HEALTHCARE, SMITHVILLE",445116,825 FISHER AVE P O BOX 549,SMITHVILLE,TN,37166,2018-10-31,684,D,0,1,GGS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation, and interview, the facility failed to evaluate and implement an appropriate positioning device for 1 resident (#24) of 2 residents reviewed for positioning and mobility of 33 sampled residents. The findings include: Review of the facility's Repositioning Policy, revised 5/30/14, revealed .Assessment for Appropriate Repositioning .Assess residents who sit or recline in a chair .Does the resident need intervention to maintain postural alignment .When a resident is up in a chair .supporting of feet . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 10/9/17 and updated 8/27/18 revealed the resident utilized a .(specialized wheelchair) . (a wheelchair that tilts, rocks and reclines) for mobility. Continued review revealed the resident required assistance with all activities of daily living (ADL). Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and hygiene, and total dependence of 2 staff with transfers. Further review revealed the resident was on pain management and utilized a wheelchair for mobility with extensive 1 staff assistance. Observation of Resident #24 on 10/29/18 at 11:05 AM, 12:19 PM, and 2:05 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position without a foot pedal on the right side of the wheelchair. Continued observation revealed the bilateral lower extremities (BLE) dangled freely from the wheelchair. Further observation revealed the foot pedal that was in place on the left side of the specialized wheelchair was extended further than the foot and did not allow the foot to rest on the pedal. Observation of Resident #24 on 10/30/18 at 8:00 AM, 8:47 AM, 9:05 AM, 1:20 PM, and 3:30 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position. Continued observation revealed there was no support for the BLE which allowed the BLE to dangle freely from the wheelchair. Observation of Resident #24 and interview with Licensed Practical Nurse (LPN) #1 on 10/31/18 at 8:45 AM, on the 100 hall, revealed .we lost one of her foot pedals . Interview with Resident #24 on 10/31/18 at 11:45 AM, on the 100 hall activity room, revealed the resident preferred her lower legs elevated. Interview with the Director of Nursing (DON) on 10/31/18 at 11:55 AM, in the resident's room, confirmed the resident did not have a foot pedal on the right side of the wheelchair or BLE support. Further interview confirmed the specialized wheelchair needed foot rests, support or cushions to elevate the BLEto aid in the resident's positioning and comfort.",2020-09-01
315,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2019-05-01,880,D,0,1,YI4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to store an ice scoop under sanitary conditions for 1 of 2 (200 Hall) ice storage areas and failed to ensure practices were followed to maintain infection control for 1 of 1 (Resident #25) sampled residents observed during perineal care. The findings include: 1. The facility's Safety & (and) Sanitation Best Practice Guidelines policy dated 11/2017 documented .the handle of the scoop must be stored so that it does not touch the ice . 2. Observations in the 200 Hall nourishment room on 4/29/19 at 11:30 AM and at 3:39 PM, revealed the ice scoop was stored inside the portable ice bin on top of the ice. Interview with the Director of Nursing (DON) on 4/30/19 at 11:40 AM. in the 100 Hall, the DON was asked if it was acceptable for the ice scoop to be stored inside the ice bin. The DON stated, No. 3. The facility's undated Perineal Care policy documented, .To provide cleanliness and comfort to the patient .prevent infections .Remove gloves and discard. Wash and dry your hands . 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 4/29/19 at 11:37 AM, revealed Certified Nursing Assistant (CNA) #2 provided perineal care to Resident #25. CNA #2 did not remove the soiled gloves used during the perineal care. After performing the perineal care, CNA #2 assisted the resident to sit on the bedside, took the resident's hairbrush, and began brushing and touching Resident #25's hair. Interview with the DON on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to perform perineal care and wear the same gloves to brush a resident's hair. The DON stated, No.",2020-09-01
316,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2018-06-19,761,D,0,1,CB2S11,"**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 stored and secured in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . 2. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed 5 unsecured syringes containing 5 milliliters of [MEDICATION NAME] 100 units/milliliter (an anticoagulant medication). Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the [MEDICATION NAME] syringes. The DON stated, No. The DON confirmed the medication was not secured.",2020-09-01
317,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2018-06-19,921,D,0,1,CB2S11,"**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 as evidenced by unsecured and accessible chemicals and needles stored in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's .Storage of Hazardous Chemicals policy documented, Hazardous chemicals are to be stored out of the reach of patients. Examples of hazardous materials are .[MEDICATION NAME] . 2. The facility's .EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS policy documented, .The following equipment and supplies are .maintained by the facility for the proper storage, preparation and administration of medication .needles . 3. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed a bottle of nail polish remover ([MEDICATION NAME]), 4 bottles of shave cream labeled Keep out of Reach of Children, 5 bottles of anti-perspirant deodorant labeled, Keep out of Reach of Children, 3 denture cleanser tablets, (9) 24-gauge needles, and (2) 23-gauge needles, all unsecured. Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the nail polish remover, the items labeled Keep out of reach of children, or the needles. The DON stated, No. The DON confirmed the chemicals and sharps were not secured.",2020-09-01
318,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2019-05-15,658,D,0,1,XL3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Manufacturer Guidelines, medical record review, observation, and interview, 2 of 4 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to follow the facility policy for the destruction of a medication and failed to follow facility policy for the application of a [MEDICATION NAME] during medication administration. The findings include: 1. The facility's Controlled Substance Disposal policy dated (MONTH) (YEAR) documented, .It (Controlled Substance) is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record/book on the line representing that dose . The (Named Manufacturer's) instructions for the [MEDICATION NAME] Patch, with a revision date of 12/2018 documented, .Do not apply to a skin area where cream, lotion, or powder has recently been applied . The facility's Specific Medication Administration Procedures IIB13: [MEDICATION NAME] Drug Delivery System (Patch) Application policy dated (MONTH) (YEAR) documented, .Identify the clean, hairless location on the body for patch placement . 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] - Schedule V (5) capsule; 400 mg (milligram) .po (by mouth) three times a day . Observations at the North Hall Medication Cart 2 on 5/14/19 beginning at 9:52 AM, revealed LPN #1 dropped Resident #61's [MEDICATION NAME] on top of the medication cart. LPN #1 discarded the pill into the sharps container, on her medication cart, without obtaining a witness to waste the narcotic. Interview with LPN #1 on 5/14/19 at 10:27 AM, at the North Hall Medication Cart 2, LPN #1 was asked what was the facility policy regarding medication destruction. LPN #1 stated, .I should have had another nurse witness that I had destroyed the [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked how she expected her nursing staff to destruct [MEDICATION NAME]. The DON stated, .it ([MEDICATION NAME]) is considered a narcotic and it should be witnessed by 2 nurses when destructing . 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].rivastigmine patch 24 hour; 13.3 mg / 24 hour .[MEDICATION NAME] .Once a day . Observations in Resident #21's room on 5/14/19 at 9:56 AM, revealed LPN #2 removed Resident #21's old [MEDICATION NAME] from her left arm and placed a new [MEDICATION NAME] on her right back. The right back was not cleaned prior to the new [MEDICATION NAME] application. Interview with LPN #2 on 5/14/19 at 9:56 AM, at the North Hall Medication Cart 2, LPN #2 was asked if she should have cleaned the right back area prior to administering the patch. LPN #2 stated, .No, you don't do that . Interview with the DON on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what the procedure was for applying a [MEDICATION NAME]. The DON stated, .clean the site it's ([MEDICATION NAME]) going on . Interview with Certified Nursing Assistant (CNA) #3 on 5/15/19 at 1:29 PM, at the North Hall Nurses Station, CNA #3 was asked what activities she did with Resident #21. CNA #3 stated, .I provide personal care . lotion her up . CNA #3 was asked if she applied lotion to her back after a shower or bath. CNA #3 stated, .sometimes I do put lotion on her back .and massage too .",2020-09-01
320,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2019-05-15,880,D,0,1,XL3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Lippincott Manual of Nursing Practice, 10th Edition, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #3 and #4) nurses followed practices to prevent the potential spread of infection when nebulizing equipment was not properly stored and overfill of a liquid medication was poured back into the dispensing bottle during medication administration. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th Edition, documented, .Disassemble and clean nebulizer after each use .a thorough proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs . 2. The facility's Specific Administration Procedures policy dated (MONTH) (YEAR) documented, .When treatment is complete, turn off nebulizer and disconnect T-piece, mouth piece and medication cup . 3. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME]; 0.5 mg (milligram) - 3 mg .3 ml (milliliter) .inhalation four times a day . Observations in Resident #67's room on 5/13/19 at 3:58 PM, revealed LPN #3 removed Resident #67's nebulizer mask with the reservoir after a breathing treatment had been administered. LPN #3 placed the nebulizer mask and the reservoir into a plastic bag without disconnecting the T-piece, mouth piece and reservoir. There was moisture in the mask and medicine cup when she placed the equipment into the plastic bag. 4. Medical record review revealed Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] acid liquid .250 mg / 5 ml .3.5 ml - 125 mg; gastric tube every 8 hours . Observations at the North Hall Medication Cart 1 on 5/14/19 at 10:10 AM, revealed LPN #4 overfilled the medication cup with [MEDICATION NAME] Acid. LPN #4 poured the overfill of [MEDICATION NAME] Acid back into the Resident #172's medication bottle. Interview with the LPN #4 on 5/14/19 at 10:20 AM, at the North Hall Medication Cart 1, LPN #4 was asked if it was appropriate to pour the overfill of medication back into the original dispensing bottle. LPN #4 stated, .probably not . Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what she expected her nursing staff to do when too much liquid medication was poured in the medicine cup. The DON stated, .dispose of the overfill medication in a sharps container . The DON was asked if it was appropriate to pour the overfill of medication back into the dispensing bottle of medication. The DON stated, .No, not appropriate .",2020-09-01
321,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,241,D,0,1,3XG211,"Based on observation, and interview the facility failed to provide care in a manner that ensured the residents' dignity, respect, and quality of life was maintained when 1 of 21 (Licensed Practical Nurse (LPN) #1) staff members observed during dining stood over a resident while assisting them to eat. The findings included: Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 stood over Resident #66 while assisting him to eat. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to stand over a resident while assisting them to eat. The DON stated, No, ma'am.",2020-09-01
322,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,279,D,0,1,3XG211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to ensure a resident with a contracture had a comprehensive care plan addressing the contracture for 1 of 16 (Resident #25) residents reviewed. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision making. Review of the Range of Motion section revealed, Resident #25 was limited in her upper and lower extremity on one side, required extensive assistance of two for bed mobility and was totally dependent of two persons for all other activities of daily living (ADL). Review of the care plan dated 6/15/17 revealed, Self-care deficit; requires total staff assist for all ADL needs. One of the approaches was Resident #25 would receive passive range of motion (PROM) and active assist range of motion (AAROM) exercises daily. There was no care plan found regarding her one sided upper and lower limitation. Observations on 6/27/17 at 10:38 AM Resident #25 was observed in her bed sleeping. Her right and left hand were in a fist like position. Observations on n 6/28/17 at 9:00 AM, 10:00 AM, 11:45 AM and 1:21 PM the resident was observed to be lying in bed with both of her hands to be held in a fist like position her legs were bent at the knees. Observations on 6/28/17 at 10:54 AM Resident #25 was observed in bed, pillow between legs, bilateral heel protector boots and she facing towards the door. Both of her hands remained in a fist like position and her legs were bent at the knee. During an interview on 6/26/17 at 1:51 PM, Registered Nurse (RN) 2 stated that Resident #25 had bilateral upper and lower extremity contractures. During an interview on 6/28/17 at 10:04 AM Certified Nursing Assistance (CNA) #4 stated Resident #25' s lower extremities were contracted as well as her left hand contracted. During an interview on 6/28/17 at 10:45 AM Licensed Practical Nurse (LPN) #4 stated she has worked with Resident #25 on and off for the past five years and Resident #25 has been contracted of her left hand and bilateral lower extremities since this time. During an interview on 6/28/17 at 4:25 PM with the MDS coordinator, The MDS coordinator stated she must have made an error in coding the MDS as Resident #25 has limited ROM in the bilateral upper and lower extremities. During an interview on 6/28/17 at 4:30 PM with the Assistant Director of Nursing (ADON), the ADON confirmed when a resident has contractures a care plan should be in place. There was no care plan found regarding the resident's contractures.",2020-09-01
323,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,371,D,0,1,3XG211,"Based on policy review, observation, and interview the facility failed to ensure food was served under sanitary conditions when 4 of 21 (Certified Nursing Assistant (CNA) #5, 6, and 7 and Licensed Practical Nurse (LPN) #1) staff members observed during dining failed to perform proper hand hygiene. The findings included: 1. The facility's Blood-Borne Pathogen Exposure Control Plan policy documented, .HANDWASHING PR[NAME]EDURES .When to wash hands .Before passing out trays or handling food . 2. Observations in Resident #24's room on 6/26/17 at 11:55 AM, revealed CNA #5 raised the head of the bed, opened the salad dressing and placed it on the salad without performing hand hygiene. Observations in Resident #59's room on 6/26/17 at 11:57 AM, revealed CNA #5 raised the head of the bed, opened the silverware, placed the clothing protector around the resident's neck, opened the straw and placed it in the tea, then opened the salad and the cake without performing hand hygiene. Observations in Resident #10's room on 6/26/17 at 12:00 PM, revealed CNA #5 touched the lettuce in the bowl with her bare hand, set up Resident #10's meal tray, and then served the meal to Resident #10 without performing hand hygiene. Observations in Resident #48's room on 6/28/17 at 12:05 PM, revealed CNA #6 pulled the bed linens over Resident #48 and then opened the silverware, took the lid off the glass of milk,and opened a container of ice cream without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:07 PM, revealed CNA #6 raised the head of the bed, then opened the silverware, placed a clothing protector around the resident's neck, opened the straw and placed in the drink, opened the ice cream, took the lid off the salad and then placed salad dressing on the lettuce without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 raised the head of the bed, then opened the containers of liquids and fed Resident #66 without performing hand hygiene. Observations in Resident #24's room on 6/28/17 at 8:10 AM, revealed CNA #7 turned her name badge over to the back of her uniform with her hand, then placed butter and jelly on a biscuit, opened a sugar package and placed the sugar over the cereal, and poured the milk over the cereal without performing hand hygiene. Observations in Resident #59's room on 6/28/17 at 8:13 AM, CNA #7 raised the head of the bed, then took the lids off the drinks, took the cover off the plate, then cut up a biscuit and opened the orange juice without performing proper hand hygiene. Observations in Resident #66's room on 6/28/17 at 8:35 AM, LPN #1 raised the head of the bed, moved a chair close to the bed, then began to assist Resident #66 with the meal, then lowered the bed and fed the resident more food without performing hand hygiene. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it is acceptable to touch objects in the environment and then assist the resident or feed the resident without performing hand hygiene. The DON stated, No, not without washing their hands",2020-09-01
324,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,223,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, time detail review, and interviews, the facility failed to ensure 1 resident (#1) was free from verbal abuse of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors .to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment . 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 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Interview with LPN #1 on 7/18/17 at 2:00 PM, in the conference room, revealed at times the resident would continually yell and you could hear him outside yelling Help, Help, Help. Further interview revealed LPN #1 would .assess the resident for pain, offer food, and offer a quiet environment .some days nothing seemed to help . Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed she was on medical leave and was in the facility to visit because she was bored and the facility was her second home. Continued interview revealed the CNA knew Resident #1's sitter so she went in to chat with her and while she was talking to the sitter LPN #2 came in to give Resident #1 his medications. Further review revealed a .few minutes later the resident was still yelling .the door flew open and (LPN #2) walked in and stated 'there are 2 of you in here I don't understand why you can't keep him quiet' .and then (LPN #2) walked over to the (resident) and was in his face and said 'I need you to shut the f*** up and be quiet' .You are irritating me and getting on my damn nerves . Continued interview revealed CNA #2 and the sitter discussed who they should report this to and CNA #2 decided to report the incident to CNA #4, who stated he would email the DON. Further interview confirmed Resident #1 was verbally abused by LPN #2 and CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse but failed to do so. Continued interview revealed LPN #2 remained in the facility for the rest of her shift. Interview with the DON on 7/18/17 at 5:00 PM, in the DON's office, confirmed the resident was verbally abused by LPN #2 and the facility failed to investigate the allegation timely.",2020-09-01
325,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,225,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to promptly report and investigate an allegation of abuse to the appropriate facility staff for 1 resident (#1) of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment .Employees, community consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nursing Supervisor on duty .any individual observing an incident of resident abuse or suspected resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse . 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 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse, but failed to do so. Interview with the DON on 7/18/17 at 5:00 PM revealed she was out of the facility and did not review her email until 6/20/17. Continued interview revealed staff had been educated to verbally tell someone of any allegations of abuse. Continued interview confirmed the facility failed to report and investigate an allegation of abuse timely.",2020-09-01
326,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,224,D,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, review of personnel files, observation, and interview, the facility failed to prevent neglect of 1 resident (#1) of 3 residents reviewed for neglect. The findings included: Review of the facility policy, Care Rounding & Risk Prevention Continuous And Responsive Engagement Rounding Review, undated, revealed .Actively, not passively, provide care and do so continuously. Hourly rounding is not as important as continuous rounding that moves with purposeful intent .Round at shift change .Typically, a round includes checking on the status of the 4 Ps: Pain Assessment Potty (toileting) needs Positioning Possessions (in reach of the Resident, including call button) . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 2/6/17 revealed .Reposition every 2 hours during the day when in bed or chair. Reposition during the night every 2 hours . Further review revealed the resident required supervision with transfer, mobility using a walker, bed mobility (and at times 1 staff support with bed mobility) and toileting. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of the MDS, Functional Abilities dated 7/14/17 revealed bed mobility, transfer, and toilet use coded 2 (limited assistance); walk in room and corridor, locomotion on and off unit, dressing and personal hygiene coded 1 (supervision, oversight). Medical record review of the Medication Record for 8/2017 revealed .[MEDICATION NAME] 3 mg (milligrams) tablet- 1 tab by mouth at bedtime ([MEDICAL CONDITION]) .[MEDICATION NAME] 30 mg tablet- 1 tab by mouth at bedtime .Major [MEDICAL CONDITION] .[MEDICATION NAME] (anti-anxiety medication) 2 mg tablet .Hour of Sleep For Anxiety .Monitor for [MEDICAL CONDITION]- Hour of sleep . Continued review revealed on 8/18/17 the nurse had initialed the resident had been monitored for [MEDICAL CONDITION] after receiving medications for anxiety and sleep. Review of the Safety Event Entry dated 8/19/17 at 7:30 AM revealed the resident was found on the floor, covered with a blanket, by the Day Nurse. The resident told her she had been .laying there all night . The resident was not harmed and the family and physician were notified with neuro (neurolgical) checks initiated. Review of the personnel files for Registered Nurse (RN) #1 dated 8/19/17 revealed .Written Warning .Medication was documented as being given to Resident #1 at 2116 (9:16) pm and was actually given at approximately 10 pm. Per [MEDICAL CONDITION] flow sheet, nurse documented that resident was not having difficulty sleeping without having physically checked the patient who had fallen in the floor . Review of the Associate Corrective Action Form for Certified Nursing Assistant (CNA) #3 dated 8/19/17 revealed .Final Written Warning .CNA failed to make walking rounds with night shift and physically check on residents. One of the residents (#1) she was accepting care for had fallen onto the floor. This patient was not found for another 1.5 hrs . Continued review revealed CNA #1 was terminated for not following the facility's policy for rounding. Review of the General Investigation Form dated 9/3/17 revealed Resident (#1) was on the floor for an undetermined about (amount) of time. She had not been rounded on since 10 pm the previous night. CNAs did not do walking rounds. Resident found at 0730ish (around 7:30 AM). No injury. Formal investigation done by DON (Director of Nursing) and ED (Executive Director) .what led to this event .Laziness on the part of CNAs involved. They did not check on resident for 10 hours .Per .night shift RN, she was still in her regular clothes when she received her night meds . Observation and interview of Resident #1 on 9/5/17 at 11:25 AM, in the resident's room, revealed the resident was sitting in her chair with her son present. Interview confirmed she did have a fall during the night of 8/18/17 but was not injured. Continued interview confirmed she was unable to get herself up or get to the call light and she laid on the floor until the next morning when a nurse entered her room. Further interview confirmed she expected a staff member would check on her during the night. Interview with CNA #1 on 9/5/17 at 1:12 PM, by telephone, confirmed she was one of the two CNAs responsible for the care of Resident #1 on 8/18/17 on night shift. Continued interview confirmed Resident #1 was independent and rang the call bell if she needed assistance. Further interview confirmed the nurse gave her medication at 10:00 PM and her door was closed. Continued interview confirmed no one told her she had to go into every room on every round. Further interview confirmed she did not enter Resident #1's room after 10:00 PM on 8/18/17. Interview with RN #1 on 9/5/17 at 3:50 PM, by telephone, confirmed she was working the night shift on 8/18/17 and was responsible for the care of Resident #1. Further interview confirmed she administered medications to the resident at 10:00 PM and neither she or the 2 CNAs entered the residents room for the duration of the night shift. Continued interview confirmed she checked on every resident when the shift started and the CNAs were to make rounds on every resident every 2 hours and at shift change. Interview with CNA #2 on 9/5/17 at 4:00 PM, by telephone, confirmed she was pulled from the 7th floor to work on the 5th floor on 8/18/17 for the night shift to help out. Continued interview confirmed CNAs were expected to check on all residents every 2 hours. Further interview confirmed they went in residents' rooms to do rounds together, but did not enter Resident #1's room to check on her because CNA #1 knew the residents so, I just followed her lead. Interview with the Director of Nursing (DON) on 9/6/17 at 12:35 PM, in the conference room, confirmed Resident #1 had a fall on 8/18/17, sometime after 10 PM, and was found in her room lying on the floor by the day nurse at approximately 7:30 AM on 8/19/17. Continued interview confirmed CNA #1 and CNA #2 did not check on the resident all night. Further interview confirmed RN #1 administered medication to the resident at approximately 10:00 PM and did not check on the resident after that time. Continued interview confirmed CNA #1 and #2 were suspended pending the investigation and then terminated because they did not follow the facility protocol. Further interview confirmed CNAs were expected to make Continuous and Responsive Engagement Rounding, which assessed the 4 P's and were to see each resident approximately every 2 hours.",2020-09-01
330,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-10-25,315,D,0,1,QBNE11,"**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 1 resident (#123) for a toileting program of 2 residents reviewed for urinary incontinence of 28 residents reviewed. The findings included: Review of the facility's policy Restorative Nursing - Toileting Program, revised 12/2016, revealed .Residents who are incontinent are assessed by Nursing and/or Therapy for a Toileting program to promote independence and quality of life by maintaining or improving a resident's continence .[NAME] Appropriate residents for the program may include the following: 1. Residents who are incontinent .4. Residents who require limited to extensive assistance in toilet use; 5. Residents who have difficulty notifying staff when they have the urge to void .B. Resident continence is assessed on admission, with significant changes and quarterly: 1. Check resident approximately hourly and document in the resident's medical record as continent, incontinent or soiled and level of assistance. 2. During the assessment period, associates honor the resident's request to toilet, but do not offer to take them as this interferes with the results of the incontinence pattern. 3. After 3 days analyze data .Determine patterns in frequency, volume, duration, and time of day . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 4 on the Brief Interview for Mental Status, indicating the resident had severely impaired cognitive skills, required extensive assistance of 1 person with transfers, walking in room, and toilet use, and was frequently incontinent of bladder. Medical record review of the significant change of status MDS dated [DATE] revealed the resident had a BIMS of 6, indicating the resident had severely impaired cognitive skills, required extensive assistance of 1 person with transfers, walking in room, and toilet use, and was always incontinent of bladder. Medical record review revealed no documentation the resident's continence pattern had been documented approximately hourly for 3 days then assessed to determine a pattern of incontinence or the type of incontinence after the resident's decline in urinary incontinence. Interview with Registered Nurse (RN #1) on 10/24/17 at 3:30 PM, in the conference room, confirmed the continence pattern was not completed after Resident #123's decline in continence identified on the 6/15/17 MDS to determine if the resident would benefit from a toileting program.",2020-09-01
332,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,561,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor representative care choices for bathing for 1 resident (#7) of 13 residents reviewed of 26 residents sampled. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Date Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be completed due to the resident being rarely or never understood. Interview with Resident #7's legal representative on 11/5/18 at 11:42 AM, in the resident's room, revealed . he should receive 3 showers weekly, but most weeks, he only gets one . Medical record review of Resident #7's Care Plan revealed, .Start 01/20/2017 .need total assistance with bathing/showering .Assist of 2 .3x (times) a week . Interview with Certified Nursing Assistant #1 on 11/6/18 at 4:04 PM, in the 6th floor nurse's station revealed, . he requires assistance of 2 .today is his bath day, and I haven't given him one yet until the nurse can help me . Medical record review of the Monthly Flow Sheet for (MONTH) (YEAR) of Resident #7's bathing schedule revealed 4 baths were missed. Further review revealed baths/showers were not given as requested per Resident #7's legal representative for (MONTH) (YEAR). Interview with the Director of Nursing on 11/7/18 at 9:42 AM, in the conference room, confirmed the facility failed to honor representative care choices for bathing for Resident #7.",2020-09-01
333,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,644,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to resubmit a PASSAR Level 1 referral with [DIAGNOSES REDACTED].#86) of 3 residents reviewed for PASARR (Pre Admission Screening and Resident Review) evaluation of 26 residents reviewed. The findings include: Review of the facility policy, PASARR (Pre Admission Screening and Resident Review) with a revised date of 7/2018, revealed .The purpose of this policy is to outline the screening of residents with a history of serious mental illness .The community will not admit any new resident who is suspected of having .A serious mental illness unless .The state mental health authority determines that the physical and mental condition of the individual requires the level of services provided by the facility .The state mental health authority determines whether or not the individual requires specialized services for mental illness .The community must incorporate communication from PASARR Level 2 determination into a resident's assessment, care planning and to his/her level of care . Medical record review revealed Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #86 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the PASARR dated 7/13/16 revealed a PASARR Level 1 screening was conducted on Resident #86. Continued review revealed .PASRR (PASARR) (LEVEL I) screen for Mental Illness & Mental [MEDICAL CONDITION] .Mental Illness (check YES or NO for each question) .NO Does the individual have a [DIAGNOSES REDACTED].g.(for example) including .[MEDICAL CONDITION] disorder .atypical [MEDICAL CONDITION] .[MEDICAL CONDITION] .NO .Does the individual have any presenting evidence of MENTAL ILLNESS .including disturbance in orientation affect or mood . Medical record review revealed no documentation a PASARR Level 2 had been conducted on Resident #86 with mental [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Consult dated 9/14/18 revealed Resident #86 was followed by psychiatric services for [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Consult dated 10/19/18 revealed .Continue [MEDICATION NAME] . I believe that hypomania (mood state characterized by persistent disinhibition and elevation (euphoria) it may involve irritation, but less severely than full mania) is probably related to recent trauma .Problem .Delusions .Status: Worsening . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #86 had a Brief Interview for Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact. Medical record review of Resident #86's Care Plan dated 10/24/18 revealed . (Resident #86's) psychosocial well-being is impaired related to GAD (Generalized Anxiety Disorder) and [MEDICAL CONDITION] disorder .(Resident #86) has alteration in mood related to h/o (history of) GAD and [MEDICAL CONDITION] disorder .(Resident #86) has impaired behavior related to h/o GAD and [MEDICAL CONDITION] disorder . Medical record review of Resident #86's Care Plan with a start date of 11/6/18 revealed .Level 1 PASRR (PASARR) is Negative .(Resident #86) will have PASRR (PASARR) completed per regulation . Medical record review of the Physician Orders and Medication Record dated 11/2018 revealed Resident #86 was ordered [MEDICATION NAME] (mood stabilizer) 125mg (miligrams) tablet delayed release by mouth every day at noon for [MEDICAL CONDITION] Disorder. Interview with the Director of Nursing (DON) on 11/07/18 at 9:33 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #86 with [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 11/07/18 at 9:45 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #86 with [DIAGNOSES REDACTED].",2020-09-01
334,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,656,D,0,1,G97W11,"**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 comprehensive care plan related to falls for 1 resident (#33) of 3 residents reviewed for falls of 26 residents sampled. Review of the facility policy, Using the Care Plan, last revised 7/2018, revealed .The care plan shall be used in developing the resident's daily care routines and will be available to associates who have the responsibility for providing care or services to the resident .Policy Interpretation and Implementation .The daily/weekly work assignments are driven from the Care Plan . Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's current care plan revealed .Falls .(Resident #33) has potential for falls related to fall history .Anti rollbacks to w/c (wheelchair) .(updated) 10/31/18 . Observation and interview with Licensed Practical Nurse (LPN) #3 on 11/07/18 at 2:42 PM, in the resident's room, revealed the resident was seated in his wheelchair and anti-rollback wheels were not in place. Interview with LPN #1 confirmed the resident was in his personal wheelchair and the anti-rollback wheels should have been in place. Interview with the Director of Nursing (DON) on 11/07/18 at 3:05 PM, in the conference room, confirmed an intervention such as anti-rollback wheels should immediately be put in place. Continued interview confirmed .if they're not on the wheelchair .clearly it's not happening . Further interview confirmed the facility failed to implement Resident #33's care plan for a fall on 10/31/18.",2020-09-01
335,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,689,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the facility fall program documentation, medical record review, observation, and interview, the facility failed to implement falls interventions for 1 resident (#33) identified as high risk for falls of 3 residents reviewed for falls of 26 sampled residents. The findings include: Review of the facility policy, Falls Prevention, revised 1/2018, revealed, .Policy Statement/Overview .Early identification of the risk for falls and reduction of falls, encourage residents to maintain the highest level of independence in a safe environment without significant risk of injury. Based on previous evaluations and current data, the associates may identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Review of the facility's Fall Program documentation, undated revealed, .Post Fall Follow-up .Daily Clinical Huddle .Day following fall, Nurse Manager to check if interventions are in place and being used properly . Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8, indicating Resident #33 had a moderate cognitive impairment, and required extensive assistance for bed mobility and transfers with assistance from 1 staff member. Medical record review of Resident #33's Falls Risk assessment dated [DATE] and 11/1/18, revealed the resident was at high risk for falls. Review of the facility Safety Event Entry dated 10/31/18, revealed Resident #33 had an unwitnessed fall on this date, and was observed sitting in the floor in front of his wheelchair beside his bed. Medical record Review of the POS [REDACTED].New Intervention .Anti-rollbacks to w/c (wheelchair) . Medical record review of the resident's current comprehensive care plan revealed, .Falls (Resident #33) has potential for falls related to fall history .Anti-rollbacks to w/c .10/31/18 . Observation and interview with Licensed Practical Nurse #3 on 11/7/18 at 2:42 PM, in the resident's room, revealed the resident was seated in his wheelchair and anti-rollback wheels were not in place. Interview confirmed the resident was in his personal wheelchair and the anti-rollback wheels should have been in place. Interview with the Director of Nursing on 11/7/18, at 3:05 PM in the conference room, confirmed an intervention such as anti-rollback wheels should be immediately put in place. Continued interview confirmed .if they are not on the wheelchair .clearly it is not happening . Further interview confirmed the facility failed to follow their policy for falls prevention.",2020-09-01
336,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,756,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure the Physician reviewed and acted upon irregularities identified by the pharmacist for 2 residents (#38 and #62) of 5 residents reviewed for unnecessary medications of 26 residents sampled. The findings include: Review of facility policy, Medication Regimen Reviews, revised 12/2016 revealed .The Pharmacist shall review the medication regimen of each resident at least monthly .Pharmacist will provide a written report or electronic via the electronic medical record to Physicians for each resident with an identified irregularity .If the Physician does not provide a pertinent response, or the Pharmacist identifies that no action has been taken .then contact the Medical Director .Copies of the drug/medication regimen review reports, including Physician responses will be maintained as a part of the permanent medical record . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Consultation Report dated 6/25/18 revealed . (Resident #38) .has a PRN (as needed) for an anxiolytic without a stop date: [MEDICATION NAME] (Anti Anxiety) 0.5 mg (Milligram) .since 6/22/18 .Recommendation: Please add a stop date . Continued review revealed the Physician did not respond to the Pharmacist recommendation. Medical record review of a Consultation Report dated 7/17/18 revealed .6/25/2018 .please add a stop date. This order ([MEDICATION NAME]) is out of compliance with CMS Regulations . Continued review revealed the Physician did not respond to the Pharmacist recommendation. Medical record review of the Physician order [REDACTED].[MEDICATION NAME] 0.5 mg tablet .4 times a day PRN . Interview with the Director of Nursing (DON) on 11/7/18 at 2:50 PM in conference room confirmed .Physician failed to follow up with Pharmacy Recommendations . Continued interview confirmed .I am responsible for following up with Physician for Pharmacy Review Recommendations . Telephone interview with the Medical Director on 11/7/2018 at 4:26 PM, in conference room, confirmed he was not aware the attending Physician was not reviewing pharmacy recommendations. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment, required extensive assistance with 1 staff member for activities of daily living, and did not experience behaviors Medical record review of the Medication Records dated 5/2018 - 7/2018 revealed .abhrp gel (compounded antipsychotic medication) .Apply 1 ML (milliliter) to inner wrist every 4 hours as needed for agitation .Start date 04/26/18 .End Date 07/26/18 . Medical record review of the Consultation Report dated 5/2/18 revealed .(Resident #62) has a PRN (as needed) order for an antipsychotic without a stop date: ABHR gel q (every) 4h (hour) prn since 4/25/18. This RX (prescription) is only good for 14 days. Recommendation .Please discontinue PRN ABHRP . Continued review revealed no documentation Resident #62's Physician responded to or acknowledged the recommendation. Interview with the DON on 11/07/18 at 12:28 PM, in the conference room, confirmed Resident #62's Physician had not responded to the pharmacy recommendations made on 5/2/18 and 6/25/18. Continued interview confirmed the facility failed to have Resident #62's Physician follow up with a pharmacy recommendation.",2020-09-01
337,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,761,D,0,1,G97W11,"Based on facility policy review, observation, and interview, the facility failed to ensure all expired medications, medication related supplies, and biologicals were discarded in 2 of 5 medication storage areas and 1 of 3 medication carts observed of 6 medication storage rooms and 6 medication carts in use. The findings include: Review of the facility policy, .Storage of Medications last revised 12/2017 revealed .The nursing associates shall be responsible for maintaining medication storage .not use discontinued, outdated, or deteriorated drugs or biologicals . Observation with Licensed Practical Nurse (LPN) #1 on 11/7/18 at 3:20 PM, in the 5th floor medication storage room, of the medication cart, revealed 44 Tylenol (medication to treat pain) 325 mg (milligram) tablets with expiration date of 10/31/18. Continued observation revealed the following expired supplies: * 2 light blue top laboratory tubes 2.7 ml (milliliter) with an expiration date of 7/31/18 * 2 blood transfer devices with an expiration date of 10/2018 Interview with LPN #1 on 11/7/18 at 3:20 PM, in the 5th floor medication room, confirmed the expired medications and supplies were available for resident use. Observation with LPN #2 on 11/7/18 at 3:42 PM, in the 6th floor medication room, revealed the following expired supplies: * 39 red top laboratory tubes 10 ml with an expiration date of 9/30/18 Interview with LPN #2 on 11/7/18 at 3:42 PM, in the 6th floor medication room, confirmed the expired supplies were available for patient use. Interview with the Director of Nursing on 11/7/18 at 5:10 PM, in the conference room, confirmed .The expired supplies should not be in the medication rooms or carts .Every Sunday night supervisors check for expired medication and supplies .we split up and go through each medication room . Continued interview confirmed the facility failed to ensure all expired medications, medication related supplies, and biologicals were discarded appropriately.",2020-09-01
339,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2019-11-20,880,D,0,1,WOBN11,"Based on facility policy review, observation, and interview, the facility failed to follow infection control practices during medication administration observations for 1 of 4 nurses observed administering medications to 1 (#7) of 5 residents. The findings include: Review of the policy, Administering Medications, dated 2/2019, revealed .Associates shall follow established community infection control procedures (e.g., handwashing, antiseptic technique, gloves) .for the administration of medications, as applicable . Observation of a medication administration with Registered Nurse (RN) #1 on 11/19/19 at 8:15 AM, on the 5th floor revealed RN #1 opened a drawer to the medication cart. Continued observation revealed the RN pulled the medication packets, removed the medications from the packets, each time placing medication in her bare hand, for a total of 11 medications. Further observation revealed RN #1 administered the medications to Resident #7. Interview with RN #1 on 11/19/19 at 8:59 AM, on the 5th floor, confirmed she had touched the medications with the bare hands during medication administration for Resident #7. Interview with Quality Assurance Director on 11/19/19 at 8:59 AM, on the 5th floor, confirmed RN #1 was to have worn gloves when touching medications for administration to Resident #7.",2020-09-01
340,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-01-09,800,D,0,1,X6DS11,"Based on facility policy review, observation, and interview, the facility failed to serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 5 halls. The findings include: Review of the facility policy dated 12/16/06 .Resident Dining Services revealed .Hot foods are served at 135 degrees or higher . Review of the resident council minutes dated 12/3/18 revealed .Dietary Food being served cold . Interview with the Resident Council on 1/7/18 at 10:30 AM in the dining room revealed hall 400 was served cold food. Observation on 1/7/19 at 1:09 PM on hall 400 revealed 18 trays on the meal cart. Further observation revealed the test tray consisted of chicken, mashed sweet potatoes, and mixed vegetables. Further observation at 1:11 PM revealed the Assistant Dietary Manager obtained the temperature of the mixed vegetables which were 112 degrees Fahrenheit. Interview with Resident #85 on 1/7/19 at 2:52 PM in her room stated .when meals are served on hall 400 they are not hot and always cold when delivered to her room . Interview with the Dietary Manager on 1/8/19 at 10:01 AM in her office confirmed .the food should be appealing, accommodating, and hot foods should be hot .",2020-09-01
341,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,223,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to prevent abuse/exploitation for 1 residents (#81) of 5 resident reviewed for abuse. The findings included: Review of facility policy, Cell Phone Policy, undated, revealed .It is Facility's policy that representatives of our organization do not use cell and /or smart phones while performing work tasks. Further, video and or pictures should not be taken of residents, PHI (Protected Health Information) and ePHI (electronic Protected Health Information) . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation revealed a written statement from Certified Nurse Aide (CNA) #2 dated 6/27/17 .I was shown a picture by (CNA #1). It was an inappropriate picture of the resident in 408B. I also witnessed (CNA #1) showing the picture at the nurse's station one night & laughing about it . Telephone interview with CNA #1 on 10/11/17 at 6:35 PM revealed she admitted taking a picture of Resident #81 while the resident was transferring from the bedside commode to the bed. It was unknown when this picture was taken. Further interview revealed the resident was not clothed from the waist down. Further interview revealed approximately 2 months later the CNA sent the picture to CNA #2 and denied showing the picture to any other staff. Interview with the Administrator on 10/11/17 at 4:30pm in her office revealed confirmed the facility failed to prevent abuse/exploitation for Resident #81.",2020-09-01
342,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,225,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to thoroughly investigate 2 allegations for 1 resident (#81) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, dated 1/19/17 revealed .Once the Administrator or designee determines that there is a reasonable cause for suspecting abuse, the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #81 had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation regarding abuse/exploitation of Resident #81 revealed no statement from the identified staff who took the picture or from Resident #81. Review of the facility investigation of an undated hand written document revealed .Res (resident) reported to nurse that $80 was missing fr (from) wallet. It has been 2-3 days since she saw it . Further review of the facility's investigation revealed 5 witness statements were obtained from staff. Interview with the Administrator on 10/11/17 at 4:30 PM in her office revealed the resident was having hallucinations when she reported the money missing. The Administrator stated the hallucinations worsened as the day progressed, resulted in the resident being sent to local hospital for evaluation. The Administrator confirmed no additional witness statements were obtained nor was a statement obtained from Resident #81. The Administrator confirmed she wrote the hand written document in the investigation. The Administrator confirmed the facility failed to thoroughly investigate 2 allegations of abuse/exploitation and misappropriation of funds for Resident #81. Interview with the Assistant Director of Nursing (ADON) on 10/11/17 at 4:45 PM in the conference room revealed the statements in the investigations were obtained by the Director of Nursing, the Administrator and the ADON. The ADON confirmed no additional statements were obtained from any additional staff, from the identified staff who took the picture of Resident #81 or from Resident #81 about either investigation. The ADON confirmed the facility failed to thoroughly complete both investigations. The facility failed to obtain statements from staff who worked prior to the money being reported missing and from Resident #81 thus the facility failed to completed a thorough investigation of the missing money per the facility. The facility failed to obtain statements from the identified staff who took the picutre of Resident #81 and from the resident thus the facility failed to complete a thorough investigation of abuse/exploitation per the facility policy.",2020-09-01
343,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,278,D,0,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess the oral status of 1 resident (#34) of 20 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] and 11/9/15 with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], the Annual MDS dated [DATE], and the Quarterly MDS dated [DATE] of the Oral/Dental Status section revealed the resident had no concerns. Observation on 10/10/17 at 9:53 AM in the Main Dining Room, on 10/10/17 at 12:40 PM in the 600 Hall area, and on 10/11/17 at 7:20 AM in the 600 Hall dining area revealed Resident #34 had several missing front teeth at the top and bottom of the mouth. Interview with the MDS Corrdinator on 10/11/17 at 12:10 PM in her office revealed she was responsible for completing the dental status section of the MDS for Resident #34. The MDS Cordinator confirmed Resident #34's dental status section on the Quarterly MDS dated [DATE], the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE] were not coded accurately.",2020-09-01
344,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,516,D,0,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to safeguard medical record information against loss or unauthorized use. The findings included: Review of facility policy, Controlled Substance Prescriptions, undated revealed .In compliance with applicable state and federal regulations, and to prevent diversion of controlled substances, the following steps must be taken when a provider completes and signs a prescription for a controlled substance in the skilled nursing facility: .Original paper prescription to be placed in a sealed envelope and delivered to pharmacy . Observation on 10/10/17 at 4:00 PM at the 600 Hall nurses station revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for [MEDICATION NAME] was stored on the desk. Further observation revealed no facility staff in the nurses station or the immediate area. Observation and interview on 10/10/17 at 4:02 PM at the 600 Hall nurses station, with the Assistant Director of Nursing (ADON) present, revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for [MEDICATION NAME] was stored on the desk. Interview with the ADON confirmed it was not facility procedure for the computer to be logged on and the paper prescription to be stored on the desk without facility staff present. Further interview confirmed the facility failed to safeguard the medical record information against loss or unauthorized use.",2020-09-01
345,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-12-18,600,D,1,1,BPQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to ensure 1 (#66) of 94 residents was free from abuse. Facility policy review Resident Rights & Facility Responsibilities, undated, revealed .The right to live in a caring environment free from abuse, mistreatment and neglect . Facility policy review Abuse Prevention Program, dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . Review of facility investigation initiated on 11/11/19 revealed Resident #24 was observed with his hand on Resident #66's torso. Continued review revealed Resident #24 was removed and placed on 1 on 1 supervision and both residents were assessed by staff with no skin issues noted. Resident #24 was sent to local hospital for further evaluation with medication adjustments made; upon return to facility the resident was moved to a different unit to a private room. Continued review revealed staff were educated on abuse from 11/11/19 through 11/22/19. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident received a [DIAGNOSES REDACTED]. Medical record review of Resident #24's Order Summary Report dated (MONTH) 2019 revealed .[MEDICATION NAME] Sprinkles 125 MG (milligram) give 1 tablet at bedtime for sexual impulsivity 11/15/19 .Flutamide 250 mg one time daily at bedtime for sexual inappropriate behaviors 11/12/19 . Medical record review of Resident #24's History and Physical dated 11/12/19 revealed .Pt (patient) is being seen per nursing request. Pt has had an episode of sexually inappropriate behavior with another resident. Pt sent to ED (emergency department) for evaluation. He was found to have mild PNA (pneumonia) and is taking [MEDICATION NAME] 750 mg by mouth daily. He returned back to the facility and has been moved to another wing away from other resident . Medical record review of Resident #24's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical behaviors directed toward others 1-3 days of the 7 day look back period. Medical record review of Resident #24's comprehensive care plan dated 5/5/19 and revised on 10/15/19 revealed .the resident exhibits sexually inappropriate behavioral symptoms related to dementia. Behavioral symptoms are manifested by: making inappropriate comment toward staff members, attempting to get females to lie down in bed with him, grabbing staff members during care. Grabs nurses and sexual remarks . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #66's MDS dated [DATE] revealed the resident was severely impaired for decision making. Continued review revealed the resident exhibited no behaviors. Medical record review of Resident #66's comprehensive care plan revealed the resident had communication impairment. Medical record review of an incident note for Resident #24 and #66 dated 11/11/19 revealed .around 17:20 - 17:25, I walked by female resident's room (Resident #66) (she was lying in bed) and noticed the resident (Resident #24) was in her room sitting in his w/c (wheel chair) beside the bed. The lights were off, so I turned the lights on as I walked in. the blanket was at the female resident's waist, her gown was around her neck and the resident had his left hand on her left breast. I immediately pulled him away, pulled the female resident's gown down and covered her with the blanket. I comforted and reassured the female resident, she was unable to tell me what happened, no obvious skin injury or other injury noted . Continued review revealed Resident #24 was taken to the nurse station and placed on 1 on 1 supervision. Interview with Resident #24 on 12/16/19 at 12:08 PM in his room revealed when asked if he touched Resident #24 on her breast he stated no, I don't remember that. Interview with the Administrator on 12/17/19 at 8:15 AM in her office revealed the facility unsubstantiated the allegation of abuse between Residents #24 and #66 due to both residents' cognition and there was no intent identified. Continued interview revealed the facility deemed the incident as a wandering, rummaging type of behavior. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/17/19 at 11:32 AM confirmed I was walking down the hall past (named) Resident #66's room when I saw another resident sitting in her room in a wheelchair beside her bed; I went into the room and turned on the light and she had her gown up close to her neck and (named) Resident #24 had his left hand on her left breast; I addressed him and he moved his hand. Continued interview she stated she removed the male resident to the hall way and assessed the female resident's skin with no issues identified. Continued interview revealed she placed the male resident in the main nurse station and notified the Assistant Director of Nursing. Continued interview revealed Resident #24 was placed on 1 on 1 supervision and was transferred to the hospital for further evaluation. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 12/17/19 at 1:14 PM in the DON's office revealed staff notified them of the incident on 11/11/19 with Resident #24 and #66. Continued interview the ADON confirmed (named) LPN #2 came to me and reported she found (named) Resident #24 in (named) Resident #66's room with his hand on her chest with her covers pulled back; I immediately notified the DON and the Administrator; (named) Resident was placed on 1 on 1 supervision and then sent to the hospital for evaluation.",2020-09-01
346,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-12-18,641,D,0,1,BPQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 (#87) resident of 32 residents reviewed for Minimum Data Set (MDS) accuracy. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's physician order [REDACTED].D/C (discharge) home 11/29/19 . Medical record review of Resident #87's Care Plan Summary Progress Note dated 11/27/19 revealed .Care plan meeting held .resident is scheduled for discharge on Friday . Medical record review of Resident #87's Progress Note dated 12/2/19 revealed Resident discharged home Friday (11/29/19) . Medical record review of Resident #87's Discharge MDS dated [DATE] revealed .Discharge Status .acute hospital . Interview with the MDS Coordinator on 12/18/19 at 9:24 AM in her office confirmed Resident #87's discharge MDS was coded to reflect the resident was discharged to the hospital; she stated I just miscoded it.",2020-09-01
348,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-02-28,637,D,0,1,L0V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.15R (MONTH) 1, (YEAR), medical record review, and interview, the facility failed to ensure a significant change in status assessment (SCSA) was completed and completed timely related to hospice services for 2 of 20 (Resident #35 and 74) sampled residents reviewed. The findings included: 1. The MDS 3.0 RAI Manual v1.15R p. 23-24 documented .A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program .The MDS completion date (Item Z0500B) must be .no later than 14 days after the determination that the criteria for a SCSA were met . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].(Named) Hospice . Medical record review revealed there was no significant change MDS assessment completed when Resident #35 was admitted to hospice. Interview with the MDS Coordinator on 2/28/18 at 12:00 PM, in the MDS office, The MDS Coordinator was asked if a change of status MDS was completed when Resident #35 was admitted to hospice. The MDS Coordinator stated, No, I do not have one. 3. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS, related to hospice services, with an Assessment Reference Date (ARD) of 10/10/17 documented a completion date of 10/23/17. A physician's orders [REDACTED].>Interview with the MDS Coordinator on 1/28/17 at 2:30 PM, in the MDS office, the MDS Coordinator was asked if the 10/10/17 MDS was completed within 14 days of the resident being admitted to hospice. The MDS Coordinator stated No, Ma'am",2020-09-01
349,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-02-28,657,D,0,1,L0V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure each resident was involved in developing the care plan and making decisions about his or her care for 2 of 2 (Resident #34 and 44) sampled residents reviewed of the 11 residents interviewed about participation in care planning. The findings included: 1. Medical Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #34 was cognitively intact. Medical record review revealed no documentation Resident #34 participated in care planning meetings. Interview with Resident #34 on 2/26/18 at 3:45 PM, in Resident #34's room, Resident #34 was asked if she participated in her care planning meetings. Resident #34 stated, No .I have asked to be there, but have not been invited yet. Resident #34 was asked if she wanted to go to the meetings. Resident #34 stated, Yes. 2. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #44 was cognitively intact. Review of the facility's Focus Meeting Form dated 6/1/17 revealed no interdisciplinary team signatures. Resident #44 had not signed the form. Review of the care plan for Resident #44 revealed that the care plan was revised on 1/26/18. Interview with Resident #44 on 2/26/18 at 5:04 PM, on the front lawn of the facility, Resident #44 stated that he had not been invited to participate in care planning meetings. Interview with the Social Services Director on 2/28/18 and 8:25 AM, in the Social Services office, the Social Services Director confirmed that there were no interdisciplinary team signatures on the Focus Meeting Form and confirmed that Resident #44 had not signed the form. The Social Services Director confirmed that Resident #44 had not participated in any care planning meetings since that time. 3. Interview with the Director of Nursing (DON) on 2/28/18 at 9:10 AM, in the DON office, the DON was asked if she expected alert and oriented residents to participate in their care planning meetings. The DON stated, Yes, absolutely. The DON was asked if residents or family members should be invited to care planning meetings on a quarterly basis. The DON stated, Yes. Interview with the MDS Coordinator on 2/28/18 at 8:35 AM, in MDS office, the MDS Coordinator was asked if residents and family members should be invited to the care plan meetings. The MDS Coordinator stated, Yes, Absolutely.",2020-09-01
350,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-12-20,689,D,0,1,776311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of fall investigation reports, and interview, the facility failed to ensure that fall investigations were completed for 1 of 18 (Resident #57) sampled residents reviewed for falls. The findings included: 1. The facility's PROTECTION/PREVENTION PROGRAMS-FALLS PREVENTION PROGRAM policy revised 8/13/13 documented, . (Named facility) takes a person centered approach to falls prevention. Comprehensive assessment and root cause analysis are two very important tools in the prevention of falls and the recurrence of falls .a Falls Committee .monitors falls and utilizes data to systemically address falls . 2. The facility's INCIDENT AND ACCIDENT PR[NAME]ESS revised 8/13/13 documented, .Investigation into the incident/accident: -Obtain information on what happened-what was actually seen or heard. If not witnessed, get patient's statement about what happened .Document all known facts, results of assessment including complete description of injuries, treatment, notification of physician and family. Gather statements from persons having information that may be pertinent . 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of fall investigations for resident #57 dated 11/13/18, 12/2/18, and 12/10/18 revealed the fall investigation was incomplete. Interview with the Director of Nursing (DON) on 12/20/18 at 6:17 PM, in the 300 hall, the DON confirmed that the fall scene investigation was not attached to the 11/13/18, 12/2/18, and 12/10/18. The DON was asked if the fall investigations were complete. The DON stated, .no these are not complete .",2020-09-01
353,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,309,D,0,1,CP8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to follow a physician's order for medication administration for 1 resident (#58) of 21 sampled residents. The findings included: Medical record review revealed Resident #58 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the medication was signed by the Licensed Practical Nurse (LPN) #1 for 8:00 AM. Observation of Resident #58 on 2/1/17 at 10:30 AM, sitting in a geri-chair in the dining room. Continued observation revealed the Assistant Director of Nursing assisted Resident #58 with breakfast and the resident ate 75% of her meal. Interview with LPN #1 on 2/1/17 at 4:15 PM, at the 200 nurse's station confirmed the LPN failed to follow the physician's order and gave the medication without food.",2020-09-01
354,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,431,D,0,1,CP8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's instructions, observation, and interview the facility failed to ensure laboratory supplies had not expired for 1 of 2 medication rooms and failed to ensure blood glucose control solutions had not expired for 1 of 3 medication carts reviewed. The findings included: Review of the manufacturer's instructions for blood glucose control solution revealed .Use the control solution within 90 days .of first opening .write the date of opening on the control solution bottle label as a reminder to dispose of the opened solution after 90 days . Observation with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:00 AM, in the Wing 2 medication storage room revealed 3 pediatric purple top specimen collection tubes with expiration date of ,[DATE]. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:11 AM, in the Wing 2 medication storage room confirmed the facility failed to monitor expired laboratory supplies. Observation with LPN #3, of the medication cart B on [DATE] at 11:30 AM, in the Wing 1 medication storage room revealed 2 bottles of the test solution for testing the accuracy of the blood glucose machine had an opened date of [DATE]. Continued observation revealed 2 bottles of test solution was open and undated. Interview with the ADON on [DATE] at 2:53 PM, in the Wing 1 medication storage room confirmed the facility failed to ensure blood glucose control solutions had not expired.",2020-09-01
355,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2019-02-27,558,D,0,1,HTMF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview the facility failed to provide a call light within reach of 1 resident (#53) of 36 residents observed. The findings include: Review of the facility policy Answering Call Lights, dated 3/2018, revealed .when the resident is confined to the bed or confined to a chair be sure the call light is within easy reach of the resident . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 15 indicating intact cognition. Further review revealed functional status required total dependence for toileting needs. Medical record review of the ADL (Activities of Daily Living) Functional/Rehabilitation Care Plan dated 2/5/19 revealed .set up necessary equipment and place within patient's reach .assist with toileting needs . Observation and interview with Resident #53 on 2/25/19 at 10:00 AM, in the resident's room, revealed the resident in her recliner yelling out .I'm wet . Further observation and interview revealed the call light wrapped around the assist railing attached to the bed located behind the resident's recliner .I can't reach it (call light) . Observation and interview with the Assistant Director of Nursing on 2/25/19 at 10:08 AM, in the resident's room, confirmed the facility failed to ensure the resident's call light was within the resident's reach.",2020-09-01
356,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2018-02-28,698,D,0,1,4KZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] clinic for 1 resident (#21) of 1 resident reviewed for [MEDICAL TREATMENT] of 31 sampled residents. The findings included: Medical record review revealed Resident #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].RESIDENT TO RECEIVE [MEDICAL TREATMENT] ON MONDAY, WEDNESDAY, and FRIDAY . Interview with the Director of Nursing (DON) on 2/28/18 at 11:20 AM, in the conference room, revealed a Post [MEDICAL TREATMENT] Report which included: date of service; pre/post [MEDICAL TREATMENT] weights; pre/post [MEDICAL TREATMENT] vital signs; lab work ordered or preformed during [MEDICAL TREATMENT]; problems that occured pre/post treatment or with shunt or catheter; and a line for the nurse to sign and date. The form was to be sent with the resident to [MEDICAL TREATMENT] and returned to the facility with the resident. Continued interview revealed the Post [MEDICAL TREATMENT] Report should be located in the resident's medical record. Medical record review from 1/18/17 to 2/28/18 revealed no Post [MEDICAL TREATMENT] Reports were present in Resident #21's medical record. Interview with the DON in the DON's office on 2/28/18 at 2:40 PM confirmed no Post [MEDICAL TREATMENT] Reports had been completed for Resident #21 from 1/18/17 to 2/28/18.",2020-09-01
358,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-09-06,225,D,1,0,KIGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility staff failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. Review of the facility policy Patient Protection and Response to Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, dated 11/28/16, revealed .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately . Review of a facility investigation revealed a witness statement completed by Certified Nursing Assistant (CNA) #3 dated 8/10/17. Further review revealed CNA #3 alleged she witnessed CNA #4 stuff a wash cloth in the mouth of Resident #1 on 8/6/17 (4 days prior) and .(CNA #4) told her (Resident #1) that she better shut up because she had[***]all over her and we were cleaning her up . Continued review revealed CNA #3 reported the allegation to CNA #2 and Registered Nurse (RN) #1 on 8/10/17. Further review revealed CNA #2 and CNA #3 reported the allegation to Licensed Practical Nurse (LPN) #2 on 8/10/17 before the start of the evening shift (7:00 PM) and LPN #2 immediately called the Director of Nursing. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 8 (moderate cognitive impairment). Continued review revealed the resident was resistant with care 1-3 days during the 7 day look back period. Further review revealed the resident required maximum assist with transfers, dressing, and personal hygiene with 2 person assist. Interview with the Director of Nursing (DON) on 9/5/17 at 11:35 AM, in the conference room, confirmed she was notified by LPN #2 on 8/10/17 at approximately 7:00PM of the allegation of abuse (4 days after the alleged incident). Interview with CNA #2 on 9/6/17 at 7:00 AM, in the conference room, revealed .was working with (CNA #3) on Sunday (8/10/17) .she (CNA 3#) told me would not believe what (CNA #4) had done to (Resident #1) .ask if she reported it .she said no . Interview with RN #1 on 9/6/17 at 7:15 AM, in the conference room, revealed . was leaving work (8/10/17) that morning .had clocked out . (CNA #2) called me over to the table and made (CNA #3) tell me what (CNA #4) had done on Wednesday (8/6/17) .DON was not there that morning so I planned to catch her the next morning . Telephone interview with LPN #2 on 9/6/17 at 11:55 AM revealed .was on break (8/10/17) when 2 night shift CNA's were getting ready to start their shift told me what had happened (on 8/6/17) .immediately called the DON . Interview with the DON on 9/6/17 at 9:00 AM, in the conference room, confirmed she would have expected to have been notified immediately of the allegation of abuse and the facility failed to do so. Interview with the Administrator on 9/6/17 at 9:05 AM, in the conference room, revealed facility staff .should have followed the policy as they were trained . Continued interview confirmed the facility failed to follow facility policy.",2020-09-01
359,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2017-05-18,225,D,1,0,M21J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, review of employee time punches, and interview the facility failed to report an allegation of abuse to the state agency and failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Abuse-Adult, revised 2/15 revealed .all alleged violations .involving .abuse .are reported immediately or as soon as possible (but not to exceed 24 hours after discovery of the incident) to the administrator (or his/her designated representative) .Any employee suspected or involved in abuse will be sent home immediately and not return to work until the investigation is complete .State survey and certification agency should be notified as soon as possible but not to exceed 24 hours after discovery of the incident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 was discharged to home on 3/28/17. Medical record review of a Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview for Mental Status score (a test for cognitive ability) of 13/15 indicating the resident was cognitively intact for daily decision making skills. Review of the facility investigation dated 3/27/17 revealed Resident #1 alleged Certified Nursing Assistant (CNA) #1 yelled at the resident when he assisted her in the bathroom on 3/25/17 at 2:30 PM. Review of CNA #1's time punches revealed CNA #1 worked 6:18 AM - 7:00 PM on 3/25/17 and 6:16 AM - 7:09 PM on 3/26/17. Telephone interview with Resident #1 on 5/15/17 at 3:47 PM, confirmed the resident reported the incident with CNA #1 to Licensed Practical Nurse (LPN) #1 on 3/25/17 immediately following the incident. Interview with LPN #1 on 5/16/17 at 4:22 PM, in the conference room confirmed Resident #1 reported CNA #1 had yelled at her while assisting the resident in the bathroom. Further interview confirmed CNA #1 continued to work after the alleged incident on 3/25/17 and on 3/26/17. Continued interview confirmed LPN #1 did not report the incident to the Administrator or the Director of Nursing (DON). Interview with the DON on 5/17/17 at 10:43 AM, in the conference room confirmed the DON was not aware of the alleged incident until Resident #1 told her on the morning of 3/27/17 at 8:30 AM. Interview with the Administrator on 5/17/17 at 11:25 AM, in the conference room confirmed he was not notified of the alleged incident which occurred on 3/25/17 until the morning of 3/27/17. Continued interview confirmed the facility failed to suspend CNA #1 pending the investigation results and failed to report the allegation of abuse to the state agency per facility policy.",2020-09-01
360,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2019-09-18,661,D,0,1,7EIV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to complete a discharge summary, including a final summary of the resident's status at the time of discharge and a post-discharge plan of care, for 1 resident (#38) of 3 residents reviewed for transfer/discharge. The findings include: Review of the facility policy Discharge Policy and Chart Order, dated 6/2019, revealed .upon discharge of a resident .complete the discharge summary .Discharge Planning Assessment . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 6/13/19 revealed .Initial Goals .Discharge to community . and .Discharge Plans .home c (with) husband . Medical record review of the 5 day Minimum (MDS) data set [DATE] for Resident #38 revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating the resident was cognitively intact and received Occupational and Physical Therapy. Medical record review of the Discharge Summary dated 6/19/19 revealed the facility documented the resident left the facility AMA (against medical advice), written on the top of the page, .went out for an apt (appointment) c (with) husband and never returned . Continued review revealed her condition at the time of discharge .unknown went to an appt & (and) never returned . Further review revealed no documentation of any specific plan of care follow-up instructions for discharge home information including home health care, follow up appointments, or post discharge activity. Medical record review of a Progress Note dated 6/19/19 at 7:15 PM, revealed .Resident's husband signed her out .husband unable to tell me who doctor was .has not returned .reported to DON (Director of Nursing) and Social Worker . Interview with the VP (Vice President) Support Services, Administrator, and the Social Worker on 9/18/19 at 10:40 AM, in the Conference Room revealed the husband returned to the facility on [DATE] to pick up Resident #38's belongings. Further interview confirmed Resident #38's medical record contained no documentation or interaction with the family on 6/20/19. Continued interview with the VP Support Services confirmed the facility did not mail a discharge plan of care including home health care and follow up appointments .we should have .we have a lot of work to do . Continued interview confirmed the facility failed to complete the discharge summary with a post discharge plan of care to assist Resident #38 in her return to home.",2020-09-01
361,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2017-09-20,502,D,0,1,D0BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure laboratory tests were completed for 1 (#109) resident of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].BMP (Basic Metabolic Panel) every week on Thursday .Ammonia Level every week on Thursday . Medical record review revealed no laboratory results for the BMP or Ammonia Level on 8/31/17 (Thursday). Interview with the Director of Nursing on 9/20/17 at 11:15 AM, in the conference room, confirmed the laboratory tests were not completed on 8/31/17.",2020-09-01
362,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,584,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to maintain cleanliness for 10 of 28 privacy curtains observed on 1 of 3 hallways. The findings include: Review of the facility policy un-named (housekeeping), undated, revealed .2. AS REQUIRED .e. Launder cubicle curtains . Observation on 9/30/18 from 9:15 AM to 12:50 PM, on the 200 Hall, revealed soiled or stained privacy curtains in rooms 217-A, 219-B, 221-B, 222-A, 225-A, 226-A, 226-B, 227-A, 229-A and 229-B. Observation and interview on 10/1/18 at 8:30 AM, with the Assistant Director of Nursing (ADON), in room [ROOM NUMBER]-A, confirmed the privacy curtain had 2 brown smudges and was soiled. Observation and interview on 10/2/18 at 10:20 AM, with the Director of Nursing (DON), confirmed the privacy curtains in resident rooms 217-A, 219-B, 221-B, 222-A, and 225-A, were either stained or soiled. Observation and interview on 10/2/18 at 10:30 AM, with the ADON, confirmed the privacy curtains in resident rooms 226-A, 226-B, 227-A, 229-A, 229-B were either stained or soiled. Interview with the Housekeeping Manager on 10/2/18 at 11:15 AM, in the conference room, revealed .if a curtain is stained it would be pitched and a new one would be replaced. Further interview revealed the privacy curtains had not been laundered on the 200 hall.",2020-09-01
363,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,656,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to work with 1 resident (#16) in the care plan process to support the resident's choices, and desired outcomes of 36 residents reviewed. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission 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 was assessed as having no plans for discharge from the facility. Observation of the resident on 9/30/18 at 10:00 AM, revealed the resident in her wheelchair with the left foot resting on top of the right foot. Continued observation revealed the resident propelled herself with her right foot up and down the hallways. Interview with the resident on 10/1/18 at 9:00 AM, in her room, revealed the resident expressed questions about her diet as ordered and complained about information not being forthcoming related to her discharge plan. Further interview revealed she had not been included in a care plan meeting or had a care plan shared with her. Interview with the Social Services Director on 10/2/18 at 7:45 AM, in her office, confirmed the resident was assisted by an outside resource for housing and a tentative discharge was being planned. Continued interview confirmed the facility's interdisciplinary team (IDT) had not met with the resident, and confirmed the resident was responsible for her own decisions. Interview with the MDS Nurse on 10/2/18 at 11:10 AM, in the conference room, confirmed the IDT met to develop Resident #16's plan of care and did not include the resident. Continued interview confirmed the facility failed to include the resident in the developement of the resident's plan of care.",2020-09-01
364,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,689,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of Incident/Accident reports, observation and interview, the facility failed to develop and implement an intervention to prevent future falls from a wheelchair for 1 resident (#36) of 4 residents reviewed for falls of 36 sampled residents. The findings include: Review of the facility policy QM (quality management) REVIEW AND REPORTING: DATA SOURCES, revised 8/13/13, revealed .examples of incidents/accidents are: Falls .Potential Hazards: .Equipment .Wheels not locked on wheelchairs .Defective or broken equipment .1. Investigation .Obtain information on what happened .get patient's statement about what happened .Review the Care plan for any possible updates that might be required related to a change/update . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was 15, indicating the resident was cognitively intact. Continued review revealed the resident was assessed as requiring the assistance of 1 staff member for transfers and used a wheelchair for mobility and locomotion. Further review revealed the resident had 1 fall since previous MDS assessment completed 11/13/17. Review of Incident/Accident reports for Resident #36 revealed the following: 1. A fall on 4/8/18 at 3:10 PM, with no apparent injury .sitting on floor on bottom in front of w/c (wheelchair) .Pt (patient) stated he was trying to reach for his coke when fell .lost his balance .Post incident interventions .Reacher .pt to be provided with a reacher to assist with getting objects .history of falling . 2. A fall on 7/30/18 at 7:10 PM, with no apparent injury .lying on the floor .left side with left arm tucked underneath him .Patient's statement regarding the incident .stated he had dropped his jello onto the floor and was reaching to get it when the wheelchair slipped out from him .Summary .Pt stated the wheelchair slipped out from under him . 3. A fall on 7/31/18 at 10:00 AM, with Type of Injury - Bruise/discoloration, - Abrasion Location of Injury - Upper back, - Lower back, - Left hip .assess patient's w/c noted antiroll back was not working properly and also brakes not working properly .Location of incident - Patient's Bathroom .Patient's statement regarding the incident pt states he was transferring to the toilet when his wheelchair rolled away from him .Post incident interventions .Maintence (maintenance) to Check brakes and antiroll back to w/c . Medical record review of the current Care Plan, last updated 9/27/18 revealed, .Patient is at risk for falls . Continued review revealed 19 interventions were included to address repeated falls over the previous 17 months and none of the interventions included locking the wheelchair brakes when resident was using. Observation and interview with Resident #36 on 9/30/18 at 10:30 AM, in the resident's room revealed the resident seated in his wheelchair in his room. Continued observation revealed no other wheel chairs in the room. Interview with the resident, at the same time, revealed when the resident was asked if he had fallen in the facility, the resident responded, .A few months ago . Observation and interview with Resident #36 on 10/2/18 at 10:35 AM, revealed the resident sitting in his wheelchair with the brakes unlocked. Interview revealed the resident got up before breakfast, spent the majority of the day in his wheelchair, and did not routinely apply the brakes on the wheelchair. Interview with the Director of Nursing (DON) on 10/2/18 at 9:00 AM, in the 200 hall nursing station, confirmed Resident #36 had 2 falls on consecutive days 7/30/18 and 7/31/18. Continued interview revealed the resident's statement on 7/30/18 the wheelchair slipped out from under him was not addressed. Further interview confirmed the wheelchair brakes and antiroll back mechanism were not assessed until after the 2nd fall from the wheelchair on 7/31/18. Continued interview confirmed the wheelchair brakes and antiroll back mechanisms were .not working properly . Interview with the maintenance supervisor on 10/2/18 at 12:20 PM, in the conference room, confirmed the work order to fix Resident #36's wheelchair was received and completed on 7/31/18 (after the 2nd fall from the wheelchair). Continued interview confirmed the wheelchair brak and antiroll back mechanism were not funtioning correctly. wheelchair brake was broken and the antiroll back mechanism had malfunctioned. Further interview revealed .one of the brake handles was completely broken off . Interview with the DON on 10/2/18 at 12:30 PM, in the conference room, confirmed the broken wheelchair brakes, and the antiroll back mechanism malfunction was not addressed until after the second fall on 7/31/18.",2020-09-01
365,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,761,D,0,1,0PSU11,"Based on observation and interview, the facility failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms. The findings include: Observation with Licensed Practical Nurse (LPN) #1 on 10/2/18, at 10:22 AM, of the 300 hall medication room, revealed the following expired medication stored in the locked cabinet: 1 bottle of 60 stool softener tablets expired 7/18. Interview with LPN #1, on 10/2/18, at 10:22 AM, in the 300 hall medication room, confirmed the medication was expired, available for resident use, and had not been properly disposed of.",2020-09-01
366,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2019-10-30,689,D,0,1,ZDV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, fall investigation review, observation and interview, the facility failed to provide interventions to prevent accidents for 1 resident (#15) of 5 residents reviewed for falls. The findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan, dated 2/6/19, and edited on 7/29/19 and 10/29/19, revealed Resident #15 had a history of [REDACTED].Reposition/Re-adjust patient in chair when she becomes restless and agitated .alarm to bed and layback (facility's name for the resident's type of chair) . Medical record review of Resident #15's Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, extensive assistance with 1 person physical assist for locomotion, and the resident was not steady when moving from a seated to a standing position. Review of an undated Manager Investigation of Incident and an Event Report dated 6/1/19 revealed Resident #15 had a witnessed fall, without injury, on 6/1/19 at 6:07 PM, while seated in a gerichair (type of reclining chair) at the nurse's station. The resident slid to the edge of the foot rest, and then slid from the foot rest to the floor. Continued review revealed .Alarm was not sounding when patient fell , alarm was replaced . Further review revealed .OLD ALARM WAS SOUNDING BUT SEEMS TO HAVE A SHORT FROM PATIENT FREQUENTLY PLAYING WITH DEVICE . Review of a Manager Investigation of Incident and an Event Report dated 6/25/19, revealed Resident #15 fell on [DATE] at 6:33 PM. The resident was seated in front of the dining room listening to her music when she got out of her layback chair and walked independently. The resident's alarm was not sounding and she had been seen playing with the alarm prior to standing up from the chair. Staff witnessed the resident walking, she became unstable, and was lowered to the floor. Medical record review of Resident #15's Significant Change MDS dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, was total dependence with 1 person physical assist for locomotion, and was not steady when moving from a seated to a standing position. Medical record review of Resident #15's Physical Therapy (PT) Plan of Care dated 8/23/19 revealed PT treated the resident from 7/15/19-8/23/19. Continued review revealed .Patient requires frequent verbal cues to stay on task due to poor attention span .Daily Life .condition of confusion . Medical record review of Resident #15s Fall Risk Assessment Tool dated 9/4/19 revealed the resident was a high fall risk. Review of a Manager Investigation of Incident and an Event Report dated 10/9/19 revealed Resident #15 fell on [DATE] at 2:30 PM in the dining room. The resident was participating in a singing activity when she attempted to stand up and fell from her gerichair. The resident's alarm did not sound. Observation and interview on 10/29/19 at 12:30 PM, in Resident #15's room, revealed she was seated in a Geri-chair with her daughter present. Interview with the resident's daughter confirmed .fell recently (10/9/19) .cannot stand or walk independently but will try to . Observation on 10/30/19 at 3:44 PM, at the Unit 3 nurses station, revealed Resident #15 seated in her Geri-chair with the chair with alarm in place. Interview and review of fall investigations with the Unit 3 Manager on 10/30/19 at 1:53 PM, in the conference room, confirmed the chair alarm was not sounding during the resident's fall on 6/1/19. Continued interview confirmed the Unit Manager changes the alarm batteries once a week. Further review revealed .Nurse checks alarm placement and other fall interventions q (every) shift and functionality of alarms . Continued interview confirmed a Geri-chair and a layback chair are the same chair. Further interview confirmed the chair alarm did not sound when Resident #15 exited her chair at the singing activity on 10/9/19. Interview with the Director of Nursing (DON) on 10/30/19 at 4:38 PM, in the conference room, confirmed Resident 15's alarm was not sounding at the time of the 6/1/19 and the 10/9/19 falls.",2020-09-01
367,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2020-02-21,552,D,1,0,D6D711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interviews, the facility failed to obtain consent for administration of a medication for 1 resident (Resident #1) of 3 residents reviewed for medication administration, resulting in Resident #1 receiving an appetite stimulant without approval from the resident or the resident's representative. The findings included: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 11/17/2017 showed .Our facility shall promptly notify the resident .and representative of changes in the resident's medical/mental condition and/or status . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] showed the resident scored a 6 (severe cognitive impairment) on the Brief Interview Mental Status. The resident required extensive assist for bed mobility and transfers with 2 person assist and required extensive assist for Activities of Daily Living with 1 person assist. The resident was always incontinent of urine and frequently incontinent of bowel. Review of a Practitioner's Order dated 1/27/2020, not timed, showed .Orders .[MEDICATION NAME] (appetite stimulant) 7.5 mg (milligrams) PO (by mouth) q (every) hs (hour of sleep) x (times) 7 days then (increase) to 15 mg q hs . Review of the medical record showed no documentation consent for the appetite stimulant was received from the resident or the resident's representative. During an interview on 2/21/2020 at 10:00 AM Resident #1 stated the resident's daughter .takes care of everything . During an interview on 2/21/2020 at 11:55 AM, Registered Nurse (RN) #1 stated an order for [REDACTED].#1 for her to get permission from Resident #1's daughter prior to administration of the medication. During an interview on 2/21/2020 at 12:15 PM, the Nursing Supervisor stated the facility should have obtained family consent prior to administration of the appetite stimulant. During a telephone interview on 2/21/2020 at 2:15 PM, LPN #1 stated she had not been notified a signature was needed prior to administration of Resident #1's appetite stimulant. During a telephone interview on 2/21/2020 at 2:30 PM, the Assistant Director of Nursing confirmed there was no documentation to indicate consent was obtained prior to administration of the appetite stimulant to Resident #1.",2020-09-01
368,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-04-30,569,D,1,0,0TGD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for one discharged Resident (#2) of 6 residents reviewed for Patient Trust Funds. The findings included: Review of the facility policy Resident AR (Accounts Receivable) Refund Policy not dated revealed . will review and credit balances for appropriate refund, and issue refund within 30 days based on the following: .There are no funds due to the facility by a third party payer, i.e. an insurance secondary to Medicare .Any refund will be payable to the resident, or responsible party when applicable . Medical record review revealed Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a facility document Trial Balance dated 4/25/18 revealed Resident #2 had a balance of #213.13 in his Patient Trust Fund. Interview with Resident #2's daughter, on 4/25/18 at 11:45 AM, via telephone revealed Resident #2 had discharged from the facility on 1/8/18, and neither she nor Resident #2 had received a refund check, or any notification from the facility in reference to closing his Patient Trust Account. Interview with the Business Office Assistant, on 4/25/18 at 2:00PM, in the conference room confirmed Resident #2 discharged from the facility on 1/8/18. The facility did not send a Resident Fund Management Service statement to the resident within 30 days, disclosing the balance of his Patient Trust Account. Interview with the Business Office Manager, on 4/25/18 at 2:40 PM, in the conference room confirmed Resident #2 had met the criteria for his Patient Trust Fund to be refund as of 2/12/18. Further interview confirmed the facility failed to follow their AR Refund Policy, and had not issued a refund check for Resident #2's Patient Trust Account within the required time frame.",2020-09-01
369,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,282,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement the Activities of Daily Living (ADL) comprehensive care plan for restorative services for 1 of 3 sampled residents (#326) reviewed for ADLs. The findings included: Medical record review of the [DIAGNOSES REDACTED].#326 revealed [DIAGNOSES REDACTED]. Further review revealed on 6/8/17, a new [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] revealed Resident #326 required the assistance of one staff for bed mobility and transfers and was able to walk in his room with limited assistance of one staff member. Further review of the clinical record revealed a Nursing assessment dated [DATE] indicated Resident #326 had no cognitive concerns and required supervision for bed mobility and transfers. A Nursing assessment dated [DATE] revealed the resident was full weight bearing, and self-propelled himself in the wheelchair. Review of the current ADL care plan dated 4/10/17 indicated Resident #326 required the assistance of staff for his ADL's due to his gait instability. An intervention was added to the ADL care plan on 5/18/17 to begin a restorative nursing program as directed. The clinical record had no documentation indicating Resident #326 was currently participating in a restorative nursing program. Observation of Resident #326 on 7/31/17 at 10:08 AM revealed he was ambulating with the assistance of his sister to the bathroom in his room and was ambulating with a steady gait. Observation of Resident #326 on 8/1/17 at 1:28 PM revealed he was in the hallway on the 200 Hall in his wheelchair. An interview conducted with Physical Therapy Staff #1 on 8/1/2017 at 3:40 PM in the physical therapy office revealed Resident #326 was discharged from physical therapy on 5/18/2017 as he had plateaued in his progress towards his physical therapy goals. Continued interviewed confirmed a note had been written on 5/18/2017 for instructions for Resident #326 to begin receiving restorative nursing services after being discharged from physical therapy. Continued interview verified once a resident is released from physical therapy and restorative nursing services is ordered it is the physical therapy departments responsibility to write the restorative plan and have it signed by the physician before the restorative nursing services can begin. Continue interview confirmed Resident #326 was on a restorative program prior to his recent physical therapy so when he was discharged from therapy on 5/18/2017 there had already been a prior program in place so he should have just started back with the restorative program from where he had previously left off. Continued interview confirmed there was no required signature on the back of the physical therapy form to re-initiate the prior restorative services. She verified a signature was never obtained and no new restorative plan was ever written for Resident #326 therefore he failed to receive restorative nursing services for ambulation since being recommended on 5/18/2017. An interview was conducted with the Restorative Nurse Manager Registered Nurse #4 on 8/2/2017 at 10:05 AM outside the lower level conference room. She stated she was not aware of an order to begin any type of restorative program for Resident #326 and he was not currently receiving restorative nursing services from her department. Continued interview confirmed if the therapy department determines a resident requires restorative nursing services they will write a restorative nursing program, and they will advise the restorative staff of the specific program for the resident. Continued interview confirmed Resident #326 had not received any restorative nursing service since 5/18/2017 when he was discharged from physical therapy. An interview was conducted on 8/2/2017 at 11:00 AM with the Director of Nursing (DON) and the Corporate Nurse in the DON office. They verified Resident #326 had an intervention on the current ADL care plan dated 5/18/2017 for restorative services for ambulation and those services were not implemented according to the current compressive care plan.",2020-09-01
370,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,311,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure restorative nursing services for ambulation were provided to 1 of 3 sampled residents (#326) reviewed for Activities of Daily Living (ADL). The findings included: Medical record review of the [DIAGNOSES REDACTED].#326 revealed [DIAGNOSES REDACTED]. Further review revealed on 6/8/17 a new [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] revealed Resident #326 required the assistance of one staff for bed mobility and transfers and was able to walk in his room with limited assistance of one staff member. Further review of the clinical record revealed a Nursing assessment dated [DATE] that indicated Resident #326 had no cognitive concerns and required supervision for bed mobility and transfers. A Nursing assessment dated [DATE] revealed the resident was full weight bearing and self-propelled himself in the wheelchair. Review of the most current ADL care plan dated 4/10/17 revealed a problem documenting Resident #326 required the assistance of staff for ADL's due to his gait instability. An intervention was added to the ADL care plan on 5/18/17 to begin a restorative nursing program as directed. Review of the Physical Therapy notes provided by the Corporate nurse on 8/1/17 at 10:50 AM revealed Resident #326 had been receiving physical therapy starting on 4/10/17 due to muscle weakness, difficulty walking and was noted to have a [DIAGNOSES REDACTED]. A Physical Therapy note dated 5/18/17 documented Resident #326's goal for ambulation was not met during physical therapy, and he continued to require stand by assistance due to unsteadiness and occasional loss of safety awareness when fatigued. The long-term goal indicated the resident and the staff would be trained in the restorative nursing program upon discharge from physical therapy. Observation of Resident #326 on 7/31/17 at 10:08 AM revealed he was ambulating with the assistance of his sister to the bathroom in his room and was ambulating with a steady gait. Observation of Resident #326 on 8/1/17 at 1:28 PM revealed he was in the hallway on the 200 Hall in his wheelchair. An interview was conducted with Physical Therapy Staff #1 on 8/1/17 at 3:40 PM in the physical therapy office and revealed Resident #326 was discharged from physical therapy on 5/18/17 as he had plateaued in his progress. Continued interview confirmed a note written on 5/18/17 for instructions for Resident #326 to begin receiving restorative nursing services after being discharged from physical therapy. Continued interview confirmed when restorative nursing services are ordered after a resident is released from physical therapy, it is the therapy department's responsibility to write the restorative plan and have it signed by the physician before the restorative nursing services begin. Continued interviewed confirmed a physician signature was never obtained, and a new restorative plan was never written for Resident #326; therefore, he never received restorative nursing services for ambulation after the recommendation was made on 5/18/17. An interview was conducted with Restorative Nurse Manager Registered Nurse #4 on 8/2/17 at 10:05 AM outside the lower level conference room. She stated she was not aware of an order to begin any type of restorative program for Resident #326, and he is currently not receiving any restorative nursing services from her department. Continued interview confirmed if the therapy department determines a resident requires restorative nursing services, they will write a restorative nursing program, and they will advise the restorative staff of the specific program for the resident. She verified Resident #326 had not received any restorative nursing service since 5/18/17 when he was discharged from physical therapy. An interview was conducted with Certified Nurse Aide (CNA) #4 on 8/1/17 at 3:40 PM in the hallway of the 200 Hall. She confirmed Resident #326 had done very well with ambulation in his room but stated he does lose his balance at times, becomes fatigued and is at risk for falls. An interview was conducted on 8/2/17 at 11:00 AM with the Director of Nursing (DON) and the Corporate Nurse in the DON office. They verified Resident #326 had a recommendation on 5/18/17 from physical therapy to begin restorative services for ambulation; the restorative nursing plan was not developed; and services had not been provided.",2020-09-01
371,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,333,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error for 1 resident (#438) of 5 residents observed during medication administration. The findings included: Medical record review revealed Resident #438 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Further medical record review of the acute care hospital's Patient Summary dated 7/28/17, revealed .Stop Taking These Medicines: [MEDICATION NAME] ([MEDICATION NAME] 125 mcg (micrograms) .oral tablet) 1 tab(s) ORALLY Once Daily . Medical record review of physician's orders [REDACTED].[MEDICATION NAME] 125 mcg tab, take 1 tablet by mouth once daily . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further medical record review revealed the (MONTH) (YEAR) MAR indicated [REDACTED] Observation of Registered Nurse (RN) #1 on 8/1/17 at 8:12 AM, on the main floor, revealed RN #1 administered [MEDICATION NAME] 125 mcg by mouth to Resident #438. Interview with Licensed Practical Nurse (LPN) Unit Manager on 8/1/17 at 8:44 AM, at the main floor nurse's station, confirmed [MEDICATION NAME] had been given without a physician's orders [REDACTED].>Interview with Pharmacist #1 on 8/1/17 at 2:10 PM, in the conference room, revealed the (MONTH) (YEAR) computer generated physician's orders [REDACTED]. Interview revealed A nurse and someone from pharmacy should have caught it . Interview with LPN #2 on 8/2/17 at 3:36 PM, in the conference room, confirmed the LPN checked the pharmacy generated Physician order [REDACTED]. Interview continued and LPN #2 confirmed she had not clarified whether the [MEDICATION NAME], not included in the (MONTH) (YEAR) admission orders [REDACTED]. Interview confirmed the failure to reconcile medication records accurately resulted in Resident #438 receiving [MEDICATION NAME] 125 mcg by mouth on 8/1/17 at 8:12 AM.",2020-09-01
372,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,425,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) for 1 resident (#438) of 5 residents observed during medication administration. The findings included: Medical record review revealed Resident #438 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Further medical record review of the acute care hospital's Patient Summary dated 7/28/17, revealed .Stop Taking These Medicines: digoxin (digoxin 125 mcg (micrograms) .oral tablet) 1 tab(s) ORALLY Once Daily . Medical record review of physician's orders [REDACTED].Digoxin 125 mcg tab, take 1 tablet by mouth once daily . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further medical record review revealed the (MONTH) (YEAR) MAR indicated [REDACTED].Take 1 tablet by mouth once daily . Observation of Registered Nurse (RN) #1 on 8/1/17 at 8:12 AM, on the main floor, revealed RN #1 administered Digoxin 125 mcg by mouth to Resident #438. Interview with Pharmacist #1 on 8/1/17 at 2:10 PM, in the conference room, revealed the pharmacy had entered Resident #438's medications by a faxed .New Home Medication List . from the acute care hospital on [DATE] at 1:40 PM that included . digoxin (digoxin 125 mcg . oral tablet) 1 tab ORALLY Once Daily . Interview continued and revealed the procedure was to reconcile the faxed list with the written admission orders [REDACTED]. Interview continued and confirmed the (MONTH) (YEAR) Physician Order's and the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Pharmacist #1 confirmed the pharmacy's present procedures had contributed to a medication error.",2020-09-01
373,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-09-12,644,D,0,1,CZPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#47) after the resident was identified with a possible serious mental disorder, to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) of 4 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagoses [MEDICAL CONDITION], Diabetes Mellitus, Major [MEDICAL CONDITIONS], and Hypertension. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) form dated 2/27/18 revealed no mental health [DIAGNOSES REDACTED]. Medical record review of a psychiatric progress note dated 9/13/17 revealed the resident had a [DIAGNOSES REDACTED].Psych (psychiatric) medication management for depression, aggression, crying spells .staff reports he is still having occ (occasional) crying spells .Has received scheduled [MEDICATION NAME] (antianxiety medication) and is doing better with his anxiety and restlessness .STM (short term memory) impaired, remote memory impaired, intellectual disability .Current [MEDICAL CONDITION] Medications-[MEDICATION NAME] (antidepressant medication) 10 mg. (milligrams) PO (by mouth) Q (every) day-depression .[MEDICATION NAME] 0.25 mg. PO @ (at) 2PM (and) HS (hour of sleep) for anxiety and may repeat X (times) 1 in 24 hours .[MEDICATION NAME] (antipsychotic medication) 25 mg. PO Q AM (morning) and 50 mg. PO Q HS . Medical record review of a psychiatric progress note dated 8/9/18 revealed the resident had a [DIAGNOSES REDACTED].staff report more depressed, more crying spells and thoughts that he would be better off dead expressed to one of the CNAs (Certified Nursing Assistant), charge nurse questioned him and he stated he had no plan, no intention of harming himself .his [MEDICAL CONDITION] sxs (symptoms) are managed (with) [MEDICATION NAME] and are stable . Interview with Registered Nurse (RN) #1, responsible for completing PASARRs at the facility, on 9/12/18 at 1:05 PM, at the 3rd floor nursing station confirmed the facility had not referred the resident to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services.",2020-09-01
374,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-09-12,842,D,0,1,CZPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview the facility failed to ensure a complete medical record by failing to document the administration of anticoagulant medication for 1 resident (#184) of 5 sampled residents reviewed for anticoagulation medication of 53 total sampled residents. The findings include: Review of the facility's policy Medication Administration with revision date 3/16/15 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record .Initial the record after the medication is administered to the resident . Medical record review revealed Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].xarelto (an anticoagulation medication) is for A Fib ([MEDICAL CONDITION]) - anticoagulation . Medical record review of physician's orders [REDACTED].xarelto 20 milligram (mg) tab (tablet) po (by mouth) at bedtime (a fib) . Medical record review of Resident #184's Medication Record (MAR) dated 9/1/18 through 9/30/18 revealed no documentation Xarelto had been administered on 9/1/18-9/9/18 and 9/11/18. Telephone interview with Licensed Practical Nurse (LPN) #2 on 9/12/18 at 4:00 PM, confirmed she had administered Resident #184's Xarelto on 9/1/18 but had failed to sign the medication administration record (MAR). Telephone interview with LPN #3 on 9/12/18 at 4:02 PM, confirmed she had administered Resident #184's Xarelto on 9/2/18, 9/3/18, 9/4/18, 9/5/18, 9/6/18, 9/8/18, and 9/9/18 but had failed to sign the MAR. Telephone interview with LPN #4 on 9/12/18 at 4:13 PM, confirmed she had administered Xarelto to Resident #184 on 9/11/18 but failed to sign the MAR. Telephone interview with LPN #5 on 9/12/18 at 4:15 PM, confirmed she had administered Xarelto to resident #184 on 9/2/18 but failed to sign the MAR.",2020-09-01
375,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,600,D,1,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure, dated 2/26/18, revealed .The purpose of this written .Prevention Program is to outline the preventive steps taken by the facility to reduce the potential for the mistreatment, neglect and abuse of residents . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #17 scored an 8 on the Brief Interview for Mental Status, indicating severe cognitive impairment, with short and long term memory deficits, and was totally dependent on 2 persons to transfer. Review of the facility's documentation, dated 9/5/19, revealed 2 Certified Nursing Assistants (CNA #1 and #2) were providing care to Resident #17 when CNA #1 became upset with the resident and spoke harshly to him, using foul language. Further review revealed CNA #1 was removed from resident care. Continued review revealed CNA #1 confirmed she became upset with the resident and used the F word. Review of the Director of Nursing's (DON) summary statement revealed, Two CNA's were getting (Resident #17) up and the resident became agitated. He started to flail his arms and (CNA #1) said 'Don't you f***ing hit me.' .(CNA #1) admits to saying F***ing in front of the resident and was terminated . Observation of Resident #17 on 9/16/19 from 2:35 PM until 3:15 PM revealed he was in his wheel chair, using his arms to propel himself through the front halls of his unit. Interview with the Charge Nurse on 9/16/19 at 3:15 PM, at the nursing station, revealed .(Resident #17) is normally in the hall .always mild mannered .doesn't normally resist care . Further interview revealed Resident #17 was diagnosed with [REDACTED]. Continued interview revealed the Charge Nurse had not encountered any problems with CNA #1 prior to 9/5/19 and stated .they (referring to the facility administration) don't tolerate foul language . Interview with CNA #2 on 9/18/19 at 11:40 AM, in the conference room, revealed the facility's documentation of the events on 9/5/19 was correct. Interview with the DON on 9/18/19 at 11:50 AM, in the conference room, confirmed the verbal abuse had occurred and he stated his observation and interview of Resident #17 two hours after the incident, revealed the resident had no memory of the verbal abuse.",2020-09-01
376,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,636,D,0,1,QLQ211,"**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 complete a Discharge Minimum Data Set (MDS) assessment for one resident (#19) of 3 residents reviewed for discharge MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be completed .within 14 days after the discharge date . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged from the facility on [DATE]. Medical record review of the resident's MDS assessments revealed a discharge MDS assessment for Resident #19 had not been completed from the day of discharge, [DATE], to the present day, [DATE]. Interview with the MDS Coordinator on [DATE] at 5:06 PM, in the conference room, confirmed Resident #19 expired on [DATE] in the facility. Continued interview confirmed the facility had not complete a Discharge MDS assessment for Resident #19.",2020-09-01
377,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,757,D,0,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility documentation review and interview, the facility failed to ensure unnecessary medications were not administered to 1 resident (#82) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Order, dated 6/11/19, revealed .DC (discontinue) [MEDICATION NAME] (an antibiotic used to treat infections) 500 mg (milligrams) x (for) 7 days .DC [MEDICATION NAME] (a medication used in a nebulizer machine to prevent, or relieve wheezing, coughing, shortness of breath, and chest tightness) 1.25/3 ml (milliliters) QID (4 times a day) x 10 days orders put in on wrong patient . Medical record review of the Medication Administration Record [REDACTED].Start Date 6/11/19 .Discontinue Date 6/11/19 . Continued review revealed Resident #82 received 1 dose of [MEDICATION NAME] 500 mg on 6/11/19 at 9:00 PM. Further review revealed .[MEDICATION NAME] 1.25 MG/3 ML SOLUTION GIVE TREATMENT 4 TIMES DAY FOR 10 DAYS Order Date: 6/11/19 START DATE 6/11/19 DISCONTINUE DATE 6/11/19 . Further review of the MAR indicated [REDACTED]. Medical record review of the facility's documentation dated 6/11/19 revealed .resident (Resident #82) received a wrong medication, due to the wrong order put in .the medication order belonged to an other (another) resident . Record review of the facility's documentation, dated 6/13/19, written by Registered Nurse (RN) #1 revealed .On Tuesday an order was received for (Resident #178) for antibiotic and Neb treatments .They were put in under (Resident #82) by accident . Interview with RN #1 on 9/17/19 at 3:27 PM, in the conference room, confirmed Resident #82 and #178 had similar names. Continued interview confirmed RN #1 selected the wrong resident in the computer to receive [MEDICATION NAME] and [MEDICATION NAME] on 6/11/19. Interview with Licensed Practical Nurse (LPN) #1 on 9/17/19 at 3:45 PM, in the conference room, confirmed the LPN administrated [MEDICATION NAME] and [MEDICATION NAME] to Resident #82 on 6/11/19 at 9:00 PM. Interview with the Director of Nursing (DON) on 9/18/19 at 9:34 AM, in the DON's office, confirmed Resident #82 received a dose of [MEDICATION NAME] and [MEDICATION NAME] on 6/11/19 which was ordered for Resident #178.",2020-09-01
378,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,558,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 1 resident (Resident #33) reviewed for call light accessibility. This failure had the potential to prevent Resident #33 from calling for assistance as desired and potentially prevent Resident #33's needs from being met. Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/6/2019, indicated Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. Resident #33's [DIAGNOSES REDACTED]. Resident #33 had cognitive impairments, as evidenced by a Brief Interview for Mental Status Score (BIMS) score of 3 out of 15. Resident #33 required total assist from one to two staff members with all Activities of Daily Living (ADLs). Resident #33 had functional limitations in Range of Motion (ROM) and impairment on one side in the upper and lower extremities According to Resident #33's care plan, dated 5/29/2019, Resident #33 was dependent on staff assistance for ADL's related to Weakness, Left-sided [MEDICAL CONDITIONS], and Mild Cognitive Impairment. The care plan included an undated, handwritten intervention that read, Touch pad (touchpad) call light within reach at all times while in bed. On 1/13/2020 at 10:01 AM, Resident #33 was in his room lying in bed with the touchpad call light positioned on Resident #33's right shoulder. There was a note taped to the wall which read, nurse call (call light touchpad) on resident's right side. Resident #33 had contractures noted in both arms and hands. Both arms were flexed upward towards Resident #33's chest. His right hand was flexed inward at the wrist with his fingers in a straight, fixed position. Resident #33's left hand flexed at the wrist, with his fingers bent outward at the knuckles and in a fixed position. When asked, Resident #33 was unable to reach his touchpad call light. On 1/13/2020 at 3:30 PM, an interview with Resident #33's family member, in Resident #33's room, revealed there were previous issues with Resident #33's call light not being in place. Resident #33's family member said the note was posted on the wall to remind staff where to place the call light so Resident #33 could reach it. On 1/14/2020 at 9:45 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was on the floor behind the head of the bed. Resident #33 said, this happens all the time. On 1/15/2020 at 8:46 AM, Resident #33 was observed in his room, in bed sleeping. The touchpad call light was out of reach, positioned upon Resident #33's right shoulder. On 1/15/2020 at 10:33 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was up near Resident #33's right shoulder. When asked if he could reach the touchpad call light, Resident #33 attempted to reach for the touchpad call light but was unsuccessful. Resident #33 said he lost a lot of his dexterity and was unable to reach the touchpad call light. On 1/15/2020 at 10:39 AM, in the presence of Licensed Practical Nurse (LPN) #17, Resident #33 was observed in his room, lying in bed with the touchpad call light on Resident #33's right shoulder. LPN #17 said the call light was placed too high, asked Resident #33 where a good spot would be, and repositioned the call light. On 1/15/2020 at 11:20 AM, Certified Nursing Assistant (CNA) #12 was interviewed at the nursing station on Unit 200. The interview revealed Resident #33's touchpad call light should be on his chest. If not, Resident #33 was unable to reach the touchpad call light. CNA #12 indicated the touchpad call light was sometimes on Resident #33's right shoulder and at other times on Resident #33's chest. Staff made sure Resident #33 could reach his touchpad call light, which she reported doing that morning during breakfast. CNA #12 indicated staff used the resident's Activities of Daily Living (ADL) Assistance Legend to know what was going on with the resident. CNA #12 reviewed the ADL Assistance Legend and said the ADL assistance Legend did not provide direction regarding placement of Resident #33's touchpad call light, but said that information was in Resident #33's care plan, which staff should follow. On 1/15/2020 at 11:29 AM, Registered Nurse (RN) #21 was interviewed in the activity room on Unit 100. RN #21 said resident call lights should be in place to allow residents to call for assistance. RN #21 said she would expect staff to follow Resident #33's care plan. On 1/15/2020 at 12:04 PM, during a second interview with RN #21 in the nourishment room on Unit 200, RN #21 said on 12/9/19, staff changed out the call light for a soft-touch call light (touchpad call light). Review of the care plan with RN #21 revealed the touchpad call light should be within Resident #33's reach at all times when in bed. On 1/15/2020 at 12:20 PM, Nursing MDS #5 was interviewed in the conference room adjacent to Nursing MDS #5's office. The interview revealed that Resident #33 had returned to the facility from the hospital with increased contractures, and an inability to use his hands. Within a few days of Resident #33's return to the facility, staff determined Resident #33 could no longer use a regular call light and switched the call light out for a touchpad call light. Nursing MDS #5 said she went into Resident #33's room today (1/15/20) and asked Resident #33 to use the touchpad call light, and he was unable to. Since the placement of the touchpad call light, Nursing MDS #5 acknowledged she had not reassessed whether Resident #33 was capable of using the touchpad call light since it was changed. Nursing MDS #5 said LPN #17 reported to her that Resident #33 could use the touchpad call light sometimes, but not today. Nursing MDS #5 said the touchpad call light should be within Resident #33's reach. On 1/16/2020 at 2:00 PM, Quality Assurance Infection Prevention (QA/IP) Nurse #10 was interviewed a second time, in the presence of the Director of Nursing (DON), in the conference room adjacent to the MDS Coordinators office. The interview revealed Resident #33 was recently hospitalized and returned to the facility. Resident #33 had been slowly declining, and the staff initiated a touchpad call light since Resident #33 was unable to use a regular call light. QA/IP Nurse #10 indicated she had seen Resident #33 use the touchpad call light and the CNAs checked to make sure the call light was in place daily. Review of the care plan with QA/IP Nurse #10 showed the touchpad call light should be within Resident #33's reach at all times when in bed.",2020-09-01
380,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,625,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility Admission packet, medical record review, and interviews, the facility failed to issue bed hold notices within 24 hours after transfer to the hospital for 2 of 27 sampled residents (Resident #27 and Resident #1). Findings include: Review of the facility policy titled, Attachment F-Bed Hold Policy, last revised (MONTH) (YEAR), revealed, At the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within 24 hours in care of an emergency transfer) the Resident/Resident Representative will be given a written copy of the Bed Hold Policy which specifies the duration of the bed-hold and may elect to hold open the Resident's room and bed until the Resident returns. At this time, the Resident/Resident Representative will indicate in writing whether the Resident desires or declines the bed hold. Review of the facility's Admission packet revealed the initial notice of the bed hold policy was provided to residents upon admission. This bed hold policy specified, At the time the resident is to leave the center for a temporary stay in a hospital or for therapeutic leave (or within 24 hours of an emergency transfer), the resident/resident representative will be given a written copy of the bed hold policy which specifies the duration of the bed-hold and may elect to hold open the resident's room and bed until the resident returns. At this time, the resident/resident representative will indicate in writing whether the resident desires or declines the bed hold. Resident #27 was admitted to the facility on [DATE]. Review of his clinical record revealed [DIAGNOSES REDACTED]. He had two unplanned transfers to the hospital on [DATE] returning 10/18/2019, and on 11/14/2019 readmitting on 11/18/2019. The Business Office Manager (BOM) was interviewed on 1/15/2020 at 2:09 PM in the conference room. She said she was responsible for completing the second bed hold notifications to the family members when the resident transferred to the hospital. The BOM said when a resident was transferred to the hospital, she usually found out about it the following day, and would contact the family via phone and ask if they wanted to hold the bed for the resident. She said she did not provide written notification to the family members. The BOM said there was no one else who sent bed hold notices to the residents or their representatives, and no one responsible for completing this task in her absence. The BOM said she had 3 days to send a bed hold notice to the resident or resident representatives. Review of the bed hold's policy notification binder, provided by the BOM, revealed Resident #27's representative (Family Member #1) was contacted by phone on 10/17/2019 and declined to hold the bed for the resident. The binder revealed there was no bed hold notice given (either written or via telephone) to Family Member #1 related to the 11/14/2019 emergent transfer to the hospital. Family Member #1 was interviewed on 1/16/2020 at 10:30 AM by telephone. Family Member #1 said she was not familiar with what a bed-hold notice was, and that the BOM never calls me. The Director of Nursing (DON) was interviewed on 1/16/2020 at 1:50 PM in the conference room. The DON said the BOM was responsible for contacting residents and resident representatives to provide the second bed hold notice. The DON said she did not think there was anyone assigned to provide bed hold notification to the resident or resident representatives in the BOM's absence. She said the bed hold notifications should be sent within 24 hours according to the regulations and facility policy. Resident #1 was admitted to the facility on [DATE] and was sent to the hospital on [DATE] for chest pain. Review of the clinical record revealed there was no documentation the resident was provided a bed hold notice upon transfer or within 24 hours of the transfer. During an interview on 1/15/2020 at 2:08 PM, the BOM stated when a Medicare resident was sent to the hospital, the resident had a 3 day leave of absence and after the third midnight, during the hospital admission, a bed hold notice was provided to the resident and/or the family. She further stated the bed hold notice for Resident #1 was not issued until 12/20/2019. During an interview on 1/15/2020 at 2:45 PM, with Resident #1 and Family Member #1, they stated they did not receive a bed hold notice when he was sent out on 12/17/2019.",2020-09-01
381,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,684,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and review of the Hospice Cooperative Agreement, the facility failed to implement a Bowel Movement (BM) protocol and failed to ensure effective coordination of hospice care for one resident (Resident #11) out of 15 sampled residents. These failures placed Resident #11 at risk for complications related to constipation and potential fecal impaction (a large mass of dry, hard stool that can develop in the rectum due to chronic constipation). Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/31/2019, indicated Resident #11 was receiving hospice services and had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the facility's Physician's Routine Orders for constipation, signed by the Medical Director on 1/1/2019, specified, If no BM (bowel movement) in three (3) days: Milk of Magnesia (or generic equivalent) 30 cc (cubic centimeter) by mouth every day PRN (as needed) constipation (notify MD (medical doctor) if [MEDICAL TREATMENT] resident). [MEDICATION NAME] (or generic equivalent) 5 mg (milligram) tabs (tablets) 1 (one) tab by mouth every day PRN constipation. [MEDICATION NAME] (or generic equivalent) 10 mg suppository 1 (one) PR (per rectum) PRN constipation. (Fleets) enema PR PRN if constipation not relieved with any two (2) of the above and notify the physician. Review of the BM Detail option 2 Roster dated 9/1/2019 through 1/16/2020 indicated Resident #11 did not have a documented BM for more than 3 consecutive days on 4 separate occasions as follows: 1. 9/19/2019 through 9/24/2019, 6 days without a documented BM: Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated (MONTH) 2019, showed the Physician's Routine Orders for constipation signed by the physician on 1/1/2019 were not on the MARs or TARs. The MARs and TARS did not indicate staff initiated the BM protocol on 9/22/2019 (after 3 days with no BM), 9/23/2019, or 9/24/2019. Review of the Department Notes dated 9/19/2019 through 9/24/2019 did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 2. 9/26/2019 through 10/3/2019, 8 days without a documented BM: Review of the MARs and TARS dated (MONTH) 2019, indicated the staff did not initiate the BM protocol on 9/29/2019, after 3 days with no BM. On 9/30/2019, 5 days after the last documented BM, staff received an order to administer Mirilax 17 gm PRN and Senna 8.6 mg daily. The [MEDICATION NAME] and Senna were not administered to Resident #11 on 9/30/2019. Review of the Department Note dated 9/30/2019, 5 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE GIVEN, NEW ORDERS RECEIVED FOR [MEDICATION NAME] PRN AND SENNA DAILY. The nursing note did not indicate why the nurse gave prune juice instead of MOM, as outlined in the facility's BM protocol. Review of the Department Note dated 10/4/2019, 8 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE WAS GIVE. WILL MONITOR FOR RESULTS. The nursing note did not indicate why the nurse gave prune juice instead of MOM as outlined in the facility's BM protocol. Review of the MARS and TARS dated (MONTH) 2019, indicated staff started administering Senna, ordered 9/30/2019, on 10/1/2019. The staff did not initiate the facility's BM protocol on 10/1/2019. On 10/3/2019, 8 days after Resident #11's last documented BM, staff received and initiated new orders for Senna Plus 8.6-50 mg tablets BID (twice daily). 3. 10/18/2019 through 10/23/2019, 5 days without a documented BM: Review of the MARS and TARS dated (MONTH) 2019, indicated Resident #11 received scheduled Senna 8.6 mg once a day from 10/1/2019 through 10/3/2019. On 10/3/2019 through 10/23/2019, Resident #11 received scheduled Senna Plus 8.6-50mg BID, except on 10/3/19 at 8:00 PM when the resident refused. The staff did not initiate the facility's BM protocol on 10/21/19 (after 3 days with no BM), 10/22/19, or 10/23/19. Review of the Department Notes dated 10/18/2019 through 10/23/2019, did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 4. 11/12/2019 through 11/15/2019, 4 days without a documented BM: Review of the MARs and TARs for (MONTH) 2019, indicated Resident #11 received scheduled Senna Plus 8.6 mg-50 mg BID from 11/1/2019 through 11/15/2019. Resident #11 refused one dose of Senna Plus on 11/11/2019 at 8:00 AM. The staff did not initiate the facility's BM protocol and did not administer PRN Mirilax or MOM on 11/15/19, after 3 days with no BM. On 1/13/2020 at 11:48 AM, Resident #11 was interviewed in her room. The interview revealed Resident #11 reported only having a BM once a week and had issues with constipation. Resident #11 said that her last BM was last night (1/12/2020); the staff had to give her MOM and an enema. On 1/15/2020 at 1:09 PM, Licensed Practical Nurse (LPN) #17 was interviewed at the nurses' station on Unit 200. The interview revealed the nurses run a No BM List each morning. If a resident was on the No BM List, nurses confirmed no BM with the resident. If the resident had not had a BM in 3 days, nurses administered MOM. If the resident was still on the No BM List, nurses administered a [MEDICATION NAME] suppository. LPN #17 said Resident #11 had issues with constipation; however, MOM or a suppository would usually work. LPN #17 reported initiating the facility's BM protocol on several occasions, which she reported to Hospice. LPN #17 added, sometimes, Resident #11 refused her medications and did not always eat a lot, which may contribute to her decreased BMs. On 1/15/2020 at 1:35 PM, the Assistant Director of Nursing (ADON) was interviewed in the conference room adjacent to the MDS office. The ADON said that if a resident did not have a BM in 3 days, the staff should initiate the facility's BM protocol. On 1/16/2020 at 11:06 AM, the Director of Nursing (DON) was interviewed in the main conference room across from the Administrator's office. The DON acknowledged the staff did not initiate the BM protocol when the resident did not have a documented BM within 3 days. The DON said the expectation was for staff to follow the facility BM protocol. Failure to follow the bowel protocol could potentially lead to an obstruction. Review of the Home Health and Hospice Nursing Home Cooperative Agreement, dated 8/15/2013, revealed the facility was responsible for coordinating services with the hospice provider to meet the patient's daily personal, medical, and emotional needs through utilization of the combined care plans of the facility and hospice provider. The hospice provider was responsible for communicating changes in the hospice patient's condition and/or death. The hospice provider was to provide the facility with a pink divider to be placed in the patient's medical record at the facility for hospice documentation. The Hospice guidelines in the nursing home and multidisciplinary progress notes for hospice staff was filed in this section. Review of the hospice Election of Medicare Hospice Benefit form, dated 10/23/2019, revealed Resident #11 elected hospice services effective 10/23/2019. Review of the care plan dated 11/11/2019 indicated Resident #11 chose to receive hospice services with a designated hospice provider. The care plan interventions directed staff to coordinate care with the hospice team. Review of the facility's BM Detail option 2 Roster dated 9/1/2019 through 1/16/2019 indicated Resident #11 did not have a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020, and 1/6/2020. Review of Resident #11's clinical record revealed the facility only had Hospice Aide Visit Notes from 12/16/2019 through 1/6/2020. The clinical record did not contain the Hospice Aide Visit Notes from 10/23/2019 through 12/13/2019. On 1/15/2020, the facility contacted the hospice provider and requested copies of the Hospice Aide Visit Notes from the start of hospice services on 10/23/2019. On 1/16/2020, the hospice provider faxed copies of the hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019. Review of the Hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019, (received from the Hospice provider on 1/16/20) revealed Resident #11 had a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, and 12/13/2019, which did not correlate with the facility's BM Detail option 2 Report. Review of the Hospice Aide Visit Notes dated 12/16/2019 through 1/6/2020, revealed Resident #11 had a BM on 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020 and 1/6/2020, which did not correlate with the facility's BM Detail option 2 Report. On 1/16/2020 at 12:30 PM, Registered Nurse #21 was interviewed at the nursing station on Unit 200. RN #21 said the hospice provider should have a communication binder for Resident #11 at the facility. RN #21 said when Hospice came in to see the resident, they would come up to the nursing station and verbally communicate the care and services provided, any concerns, and whether the resident had a BM, which facility staff should document in the Electronic Health Record (EHR). On 1/16/2020 at 11:49 AM, LPN #22 was interviewed on Unit 200. LPN #22 said facility staff took care of the resident and provided the overall care, and Hospice was an add-on (offers additional services). Before the hospice aide or nurse left, they would advise staff of any concerns and if the resident had a BM. If hospice staff reported a resident had a BM, LPN #22 would chart the BM in the EHR and let the CNA know. LPN #22 said the facility started hospice binders with all the hospice providers, but she was unsure why Resident #11's hospice provider did not have a binder. On 1/16/2020 at 11:55 AM, CNA #12 was interviewed at the nursing station on Unit 200. CNA #12 said Hospice provided bed baths and made sure Resident #11 had the supplies she needed. CNA #12 said Hospice came in once a week (nurse and CNA) and they would communicate specifics about the resident that staff needed to know, such as BMs, which facility staff was responsible for documenting in the EHR. CNA #12 denied any concerns with hospice staff not providing information regarding the resident. On 1/16/2020 at 12:01 PM, LPN #17 was interviewed at the nursing station on Unit 200. LPN #17 said the hospice aides came in once or twice a week, bathe the resident, provided necessary supplies, and supervised all her medications. LPN #17 said the hospice nurse came in several times a week. The hospice aides and hospice nurse would verbally communicate concerns and the care provided. If the hospice aides or nurse notified her the resident had a BM, LPN #17 notified the resident's CNA, and the CNA was responsible for charting the BM in the EHR. On 1/16/2020 at 12:11 PM, CNA #11 was interviewed at the nursing station on Unit 200. CNA #11 said the Hospice aides came in three times a week, and the nurse may come in once a week. The Hospice aides verbally communicated the care provided and whether the resident had a BM, which she would document in the EHR. CNA #11 denied any concerns with Hospice communicating information on the care provided or when the resident had a BM. On 1/16/2020 at 1:06 PM, the DON was interviewed in the DON's office. The DON said the facility required Hospice to give the facility a binder that included their care plan, signed hospice documents, agreements, signed consents, and all Hospice related documents. The hospice staff verbally communicated any change in the resident, concerns, bathing, and BMs. The DON said the facility staff was responsible for documenting information related to the care and services provided in the EHR. The DON said there was a breakdown in communication and she reached out to Hospice on 1/6/20 to advise them they needed to provide all related documents to the facility. On 1/16/2020 at 3:12 PM, Hospice Director (HD) #20 was interviewed via the phone. She said Hospice provided all new orders and information to the facility. She attended the first care conference last week, which was when she first learned that the facility was requesting Hospice to send information to the facility. HD #20 was not sure whether the hospice notes entered into their Hospice system was sent to the facility. She said there was a hospice tab in the clinical record where the Hospice nurse documented concerns. On 1/16/2020 at 3:34 PM, the Hospice Registered Nurse (RN) #15 was interviewed via the phone. Hospice RN #15 said Hospice did not provide a written note in the clinical record. If there were new orders, Hospice faxed the order over to the facility, and the facility was responsible for transcribing and initiating the orders. She said Hospice provided the facility staff with verbal communication regarding care and services provided, and the facility was responsible for documenting this information in the EHR.",2020-09-01
382,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-06-15,225,D,1,0,25IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 4 residents reviewed. The findings included: Facility Policy review of the Abuse Prevention Policy and Procedure, revised 8/2016, revealed .report all allegations of abuse immediately to the Director of Nursing and Administrator .all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty .so the resident's needs can be attended to immediately and investigation can be undertaken promptly .the charge nurse .will examine the resident .document findings in the clinical records .immediately initiate the Investigation protocol .any employee suspected of abuse, neglect, or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation .Do not wait . Medical record review revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued review revealed the patient was discharged from the facility on 6/8/17. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive assistance of 2 person with transferring, dressing, toileting, and personal hygiene, required extensive assistance of 1 person with walking in room and locomotion on unit, and supervision with eating. Medical record review of a Nursing Note dated 5/23/17 at 4:53 AM revealed .resident rang out for assistance to the restroom .both CNAs (certified nursing assistant) responded to help .resident was very inappropriate towards CNAs by cussing them out and threatening to get them fired .resident accused one CNA of pushing her in the wheelchair .CNA was only guiding .towards the chair .not the first time resident has cussed out these CNAs . Facility investigation review dated 5/23/17 revealed the incident occurred on 5/23/17 at 4:30 AM and at 6:40 AM Licensed Practical Nurse (LPN) #1 (days shift nurse) received the complaint and notified the Director of Nursing (DON) at 6:55 AM. Further review the DON interviewed the resident at 8:30 AM and revealed .stated .she put her light on at about 5:00 or 5:30 am this morning .two nurses came into the room .told them she had .to the bathroom .they (CNAs) wanted her to use the bedpan .she was supposed to be using the toilet .felt this made them mad .one (CNA) was in front of her .one behind the wheelchair .one behind the wheelchair pushed her down into the wheelchair causing her left leg to hurt .she told them nurse behind her .she was going to get her fired .going to tell her son .he would get a lawyer . Review at 10:00 AM the Social Worker interviewed the resident who stated 2 Registered Nurses (RN) came to her room to get her in her wheelchair and assist her to the bathroom .1 RN that was older with dark hair pushed her by her neck . Interview with LPN #1 on 6/13/17 at 11:53 AM in the conference room revealed .work dayshift .when I came in I got report .she (nightshift nurse) only told me the resident was all the time threatening staff with her attorney's .nothing was said about the resident making an allegation of abuse .the two CNAs on dayshift went to do the resident's blood pressure and the resident told them she had 2 CNAs last night and the older one .was helping her into her wheelchair from the bed .the CNA pushed her .said it hurt her and she felt she had been injured all over again .I reported it . Interview with RN #1 on 6/13/17 at 12:08 PM in the conference room revealed .I was assigned to her (resident) .(CNA #3) and (CNA #4) came out and informed me they were getting patient in wheelchair to go to restroom .(CNA #4) was going to assist her .because she was going to miss the wheelchair .I was new .I didn't know (to call supervisor) .(CNA #4) didn't go in room any more that night .I didn't assess her .I didn't know I was suppose to afterward . Interview with the Nurse Practitioner (NP) on 6/13/17 at 1:25 PM in the conference room revealed .she constantly complained .she did not want to be here .she was assessed and there were no signs of abuse .we did order some x-rays and they were negative . Interview with CNA #1 on 6/13/17 at 1:40 PM in the conference room revealed .me and (CNA #2) .had gone in to do her vital signs .said she had been abused .said .that girl last night .tall one .pushed her in her chair .we went and told (LPN #1) . Interview with CNA #2 on 6/13/17 at 2:50 PM in the conference room revealed .me and (CNA #1) .went in to her room cause her light was on .stated she came here for therapy not to be abused .said the CNA had pushed her down and hurt her leg .she didn't name the person .we told the (LPN #1) . Interview with CNA #3 on 6/14/17 at 6:00 AM in the conference room revealed .we had to help her to her wheelchair .I stood in front of her .(CNA #4) stood behind her .when she was fixing to sit she was going to miss the wheelchair .(CNA #4) put her hands on her hips to help assist her into the wheelchair so she would not miss it and fall .she said (CNA #4) pushed her .she was going to get her fired .we assisted her to the bathroom and back to bed .we told (RN #1) about what happened . Interview with CNA #4 on 6/14/17 at 6:15 AM in the conference room revealed .she was cussing .we got her up on the side of the bed .she got up .she was going to miss the wheelchair .I gently helped ease her over into the wheelchair so she would not fall and hurt herself .said you quit shoving me around .she was going to get someone fired .we assisted her to the restroom and back to bed .we mentioned it to the nurse I didn't take it serious .I finished working out the shift . Interview with the Administrator on 6/14/15 at 7:00 AM in the conference room revealed .we did discipline (RN #1) since she did not report the incident immediately and did not send (CNA #4) home . Interview with the Administrator and the DON on 6/15/17 at 9:25 AM in the Administrator's office confirmed the facility failed to report an allegation of abuse immediately to the DON and the Administrator and failed to suspend CNA #4 pending the investigation results per facility policy.",2020-09-01
383,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2018-10-30,609,D,1,0,B4T611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure all allegations of abuse or neglect were reported immediately to the Administrator and the State Survey Agency within 2 hours for 1 resident (#1) of 3 residents reviewed for abuse or neglect on 3 of 3 nursing units sampled. The findings included: Review of facility policy Abuse Prevention Policy and Procedure, last revised 2/26/18, revealed .1 .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the Administrator and Director of Nursing . 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 a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 10/4/18 revealed Resident #1 told Registered Nurse (RN) #2 on 10/1/18 that RN #1 did not give her all her medications. Continued review revealed RN #2 reported the allegation to the Assistant Director of Nursing (ADON) on 10/1/18, but the allegation was not reported to the Administrator or the Director of Nursing (DON). Further review revealed the incident was reported to the DON by the resident's daughter on 10/4/18. Interview with the Administrator and the DON on 10/29/18 at 2:00 PM, in the Conference Room, confirmed no one reported the allegation to them until 10/4/18 (3 days later). Telephone interview with the Administrator on 10/30/18 at 8:35 AM confirmed the ADON failed to report the allegation to the DON or the Administrator. In summary, the allegation of neglect was not reported to the DON, the Administrator, or State Survey Agency until 10/4/18 (3 days later) and the facility failed to follow facility policy.",2020-09-01
384,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-11-30,554,D,0,1,AD5V11,"**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 assess 1 resident (#4) of 7 residents reviewed for self-administration of medications. The findings included: Review of facility policy Medication Administration dated 3/16/15 revealed .prepare medications immediately prior to administration .observe that the resident swallows oral drugs .do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication . Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Observation and interview with Licensed Practical Nurse (LPN) #1 on 11/28/17 at 8:39 AM, in the resident's private room, revealed Resident #4 was alone in her room and a medication cup containing 8 pills was sitting on the resident's bedside table. Interview with LPN #1 revealed the medication cup contained the following medications: [REDACTED] *two 500 microgram (mcg) [MEDICATION NAME] tablets (medication to treat vitamin B-12 deficiency) *one 80 milligram (mg) [MEDICATION NAME] tablet (medication to treat fluid retention, [MEDICAL CONDITION], and swelling) *two 2,000 unit Vitamin D3 tablets (supplement to improve overall health or for treating [MEDICAL CONDITION]) *one 1,000 unit Vitamin D3 tablet *one 5 mg [MEDICATION NAME] capsule (Vitamin B supplement) *one 800 mg [MEDICATION NAME] tablet (medication to control phosphorus levels in people with [MEDICAL CONDITION]) Continued Interview with LPN #1 confirmed no assessment for self-administration of medications had been completed. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 11/30/17 at 9:15 AM, in the Nursing Office, confirmed Resident #4 was assessed for self-administration of medications and the facility failed to follow facility policy.",2020-09-01
386,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2018-10-02,812,D,0,1,5TK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 5 (Certified Nursing Assistant (CNA) #1) staff members placed a dirty meal tray on a cart with a clean undelivered meal tray and failed to perform hand hygiene during dining observations. The findings included: The facility's Handwashing/Hand Hygiene policy with a revision date of (MONTH) (YEAR) documented, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .l. After contact with objects (e.g. (example), medical equipment) in the immediate vicinity of the resident .o. Before and after eating or handling food . Observations in the Skilled hall on 10/1/18 beginning at 12:43 PM, revealed CNA #1 entered Resident #84's room, delivered a meal tray to this resident, and picked up a dirty tray (Resident #84's tray from breakfast) and placed this tray in the cart with 1 clean tray still left to deliver. CNA #1 then entered Resident #83's room, delivered a meal tray to this resident, and did not perform hand hygiene. CNA #1 removed a pillow and adjusted this resident's bed, and continued to set up the tray without performing hand hygiene. Observations in the Skilled hall on 10/02/18 beginning at at 8:17 AM, revealed CNA #1 delivered a meal tray to Resident #20, adjusted Resident #20's bed, touching the bed, and continued to set up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #231's room, delivered a meal tray to this resident, adjusted the bed touching the bed, and continued setting up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #83's room, delivered a meal tray to this resident, adjusted the bed, touching the bed, and moved a pillow from under Resident #83's arm, then continued to set up the tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 10/2/18 at 4:47 PM, in room [ROOM NUMBER], the DON was asked if a tray that had been in a room, had been uncovered, and that a resident had already eaten from the tray, should the tray be placed back on the cart with trays that had not been delivered. The DON stated, No. The DON was asked what should be done after assisting residents, touching objects, and before setting up a meal tray. The DON stated, .hand wash .",2020-09-01
388,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,241,D,0,1,WCXB11,"**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 care in a manner that enhanced the dignity of 1 of 2 (Resident #90) residents observed with a indwelling urinary catheter. The findings included: 1. The facility's Quality of Life-Dignity policy documented, .Demeaning practice and standards of care that compromise dignity are prohibited .Staff shall promote dignity and assist residents as needed by .Helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter with the drainage bag uncovered and in full view. Interview with the Director of Nursing (DON) on 10/30/17 at 5:24 PM, in Resident #90's room the DON was asked if it was acceptable to have the resident's indwelling urinary catheter bag uncovered. The DON stated, No.",2020-09-01
389,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,314,D,0,1,WCXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Prevention and treatment of [REDACTED].#93) sampled residents reviewed with a pressure ulcer. The findings included: The Prevention and treatment of [REDACTED].Suspected Deep Tissue Injury: Depth Unknown .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear . area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . Evolution may be rapid exposing additional layers of tissue even with optimal treatment . Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADMISSION EVALUATION AND INTERIM CARE PLAN dated 10/6/17 documented, .break down to heels bilateral .surgical incision .lumber spine . The NURSE'S NOTES documented, .10/9/17 Skin Note: L Heel .3 .cm (centimeters) blisters noted dried up. Floating Heels @ (at) night . The physician order [REDACTED].Apply skin prep to L (left) Heel Daily .Float heels as tolerated while in bed . There were no documentation the physician was notified of the skin breakdown until 10/9/17. The were no documentation of physician's orders [REDACTED]. The care plan dated 10/15/17 documented, .Problem .has impaired skin integrity related to blisters to left heel .Approach .apply skin prep to left heel daily until healed .Start Date 10/15/2017 . The WEEKLY PRESSURE ULCER PROGRESS REPORT documented, .L Heel DTI (deep tissue injury) . Date Identified .10/9/17 .Date Dr. (doctor) Notified 10/9/17 .Date 10/9/17 Length 3x (by) 3 .Black .Stage DTI .Float Heels .Weight 145 .10/11/17 .3x3 .BLK (black) .DTI .Float Heels .10/17/17 .3x3 .BLK .DTI .10/24/17 .3x3 .Weight 153 . Review of the TREATMENT RECORD for the month of (MONTH) revealed Resident #93 received application of skin prep to the left heel daily from (MONTH) 11th through 30th. Observations during wound care in Resident #93's room on 10/31/17 at 2:35 PM, revealed Resident #93 had 3 small unopened black areas on the left heel. Interview with the Treatment Nurse on 10/31/17 at 2:56 PM, in the conference room, the Treatment Nurse was informed that Resident #93 had been assessed on 10/6 with breakdown on her heel and was asked what treatment had been done for her on the 6th. The Treatment Nurse stated, .that would have been (Named Registered Nurse (RN) #2) .I didn't see her till 10/9 . The Treatment Nurse was asked when you saw Resident #93 on 10/9 what was put in place for the left heel DTI. The Treatment Nurse stated, .to float heels and (apply) skin prep .didn't write it (referring to order) till 10/11 . The Treatment Nurse was asked when you saw her on 10/9 why wasn't the order written till 10/11. The Treatment Nurse stated, .I forgot to get the order . Interview with the Director of Nursing (DON) on 10/31/17 at 3:15 PM, at the nurse's station, the DON was asked what she would expect her staff to do for a resident that had been assessed with [REDACTED]. The DON stated, .to put something in place .to notify the physician or nurse practitioner. The DON was asked if it was acceptable to wait 5 days to put a treatment in place for skin breakdown of a heel or DTI. The DON stated, No . Interview with RN #1 on 10/31/17 at 3:36 PM, in the conference room, RN #1 was asked if she completed Resident #93's admission assessment. RN #1 stated, Yes, ma'am. RN #1 was asked did she have breakdown to her heels. RN #1 stated, .yes . RN #1 was asked did you notify the physician. RN #1 stated, .I don't think so .",2020-09-01
390,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,315,D,0,1,WCXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to obtain a physicians order and medical justification for indwelling urinary catheter use for 1 of 2 (Resident #90) sampled residents reviewed with an indwelling urinary catheter. The findings included: 1. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #90 was coded for an indwelling urinary catheter. Review of the care plan dated 10/23/17 revealed, Resident #90 had an indwelling urinary catheter. Medical record review revealed no physician's orders or medical justification for the use of the indwelling urinary catheter. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter. Interview with License Practical Nurse (LPN) #3 on 10/31/17 at 2:15 PM, at the unit 1 medication cart, LPN #3 was asked if there was an order and [DIAGNOSES REDACTED]. LPN #3 stated, No it's not there. Interview with the Director of Nursing (DON) on 10/31/17 at 2:31 PM, at the unit 1 nurse's station, the DON was asked if it was acceptable to not have an order or [DIAGNOSES REDACTED]. The DON stated, .No .we did not get the order .",2020-09-01
393,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,441,D,0,1,WCXB11,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained as evidence by a mop stored in a bucket of water in 1 of 1 biohazard rooms and by a nebulizer mask and a bi-pap mask not properly stored. The findings included: 1. The facility's General Infection Control Practices policy documented, .Infection Control Considerations Related to Medication Nebulizers / Continuous Aerosol .7. Store the circuit in plastic bag, marked with date and resident's name, between uses . 2. Observations in Resident #90's room on 10/30/17 at 2:27 PM, 4:43 PM, and 5:33 PM, revealed an uncovered nebulizer mask resting on the night stand. 3. Observations in Resident #91's room on 10/30/17 at 2:50 PM, 4:52 PM, and 5:34 PM, revealed a bi-pap machine at the bedside with the mask uncovered. Interview with the Director of Nursing (DON) on 10/30/17 at 5:33 PM, in Resident #90's room, the DON was asked if it was acceptable to have a nebulizer mask uncovered on the resident's nightstand. The DON stated, No. Interview with the DON on 10/30/17 at 5:34 PM, in Resident #91's room, the DON was asked if it was acceptable to have a bi-pap mask on the resident's night stand uncovered. The DON stated, No. 4. Observations in unit 1 Biohazard Room on 10/31/2017 at 8:30 AM and 8:52 AM, revealed a mop stored in a bucket of dirty water. Interview with the Laundry/Housekeeping Supervisor on 10/31/17 at 8:50 AM, in unit 1 Biohazard Room, the Laundry/Housekeeping Supervisor was asked if a mop should be stored in a bucket of water. The Laundry/Housekeeping Supervisor stated, No it should not.",2020-09-01
394,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2019-01-09,689,D,0,1,DWFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility records review, observation and interview, the facility failed to investigate the root cause of 7 falls and develop interventions to address the specific cause of 7 falls for 1 resident (#3) of 4 residents reviewed for falls of 21 residents reviewed. The findings include: Review of the facility policy Accident Incident Reporting Policy, undated, revealed .PURPOSE: To ensure accidents .are identified, reported, investigated .To provide a database to study the cause of accidents .to provide assistance in implementing corrective actions to prevent reoccurrence when possible .13. A thorough investigation will be completed within 5 business days . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a score of 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Continued review revealed Resident #3 required extensive assistance of 2 persons for transfer, ambulated in the room [ROOM NUMBER]-2 times per week with the assistance of 1 person and was able to move around facility independently with a wheel chair. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Review of the Falls Incident Reports and concurrent review of the Manager Incident Review (identified by the Director of Nurses/DON as the fall investigation) revealed the following: 8/3/18 at 7:45 AM - .lying on bathroom floor on back .abrasion to (L) (left) middle back noted .w/c (wheelchair) in bathroom door way and wheels not locked .Intervention: Bathroom alarm applied to door . Review of the Manager Incident Review dated 8/6/18 revealed .poor safety awareness and has [MEDICAL CONDITION] .door alarm on bathroom door. 8/16/18 at 10:23 AM - .sitting on buttocks in the floor of his bathroom .Scrape noted to back .New batteries placed into bathroom door alarm. Scheduled battery changes began . Review of the Manager Incident Review dated 8/17/18 revealed Why did it happen .Doesn't remember to call for assistance. Battery on alarm going dead and soft chipper sound was heard .What will decrease likelihood of reoccurrence? Schedule door alarm battery (changes). 8/27/18 at 5:00 AM - .Heard someone yelling .entering resident's room, noted resident lying on right side on floor in front of bed .stated he was standing next to his bed to use the urinal and his knee gave out on him causing him to fall . Review of the Manager Incident Review dated 8/27/18 revealed .Stated knee 'gave on him' while using urinal .What will decrease likelihood of reoccurrence? 72 (hour) toileting. 8/31/18 at 6:10 AM - .Heard someone yelling .entered bathroom, noted resident sitting in floor .CNA (Certified Nursing Assistant) notified LPN (Licensed Practical Nurse) resident has been turning bathroom door alarm off. Intervention: Remove bathroom door alarm and apply to inside of bathroom door . Review of the Manager Incident Review dated 9/4/18 revealed .Resident removed door alarm from door. Unable to recall safety measures put into place .door alarm on inside of bathroom door. 9/5/18 at 9:45 AM - .Heard resident yell out .call light had come on .noted resident laying on (L) side with feet toward head of bed .I was trying to use urinal .' Intervention: PT (Physical Therapy) to eval (evaluate) . Review of the Manager Incident Review dated 9/6/18 revealed .Why did it happen? Res (resident) unable to recall safety precautions. He is unable to remember to use call light. He always self transfers .What will decrease likelihood of reoccurrence? Refer to PT for strengthening. 9/23/18 at 7:41 PM - .Resident .yelling from room .noted to be on floor lying on back .w/c unlocked and beside him .Resident stated trying to stand at sink to use his urinal . Review of the Manager Incident Review dated 9/24/18 revealed Why did it happen? Decreased cognition, unable to remember to push call light. Resident had pushed with foot the bedside table to the end of the bed .What will decrease the likelihood of reoccurrence? Place urinal within reach when resident is in bed. 9/26/18 at 8:50 PM - .resident was yelling from the room .lying on the floor .resident said 'I was standing and holding the sink and slipped . Review of the Manager Incident Review dated 9/27/18 revealed Why did it happen? Res has poor safety awareness, resident does not recognize physical limitations .What will decrease the likelihood of reoccurrence? Grip strips in front of sink. 10/23/18 at 9:30 PM - .Witness .Statement .'walking past resident room and noticed resident was going to sit in wheelchair and before could assist he sat in the floor and missed his chair and fell in floor' . Review of the Manager Incident Review dated 10/24/18 revealed, .Why did it happen? Res continues to stand unassisted. Frequent urination. Unable to remember to call for assistance .NP to evaluate (increase) urge in urination. 11/18/18 at 6:34 PM - .Called to resident's room per CNA .Resident stated he was going to get his water pitcher and his knees went out on him, causing him to fall, knocking water pitcher off .offer resident a lighter weight pitcher . Review of the Manager Incident Review dated 11/19/18 revealed, Why did it happen? Res stood and knees weakened causing him to fall .What will decrease likelihood of reoccurrence? Lighter weight water pitcher . 11/28/18 at 12:05 PM - .Resident noted laying in floor on back .in front of sink .Intervention: Therapy to evaluate for correct way to use urinal and if grab bars needed at sink .Other Info (information) Resident stands at sink to use urinal with balance problem noted with standing and unable to stay balanced when trying to hold urinal and to position .correctly in urinal . Review of the Manager Incident Review undated revealed .Resident states he was trying to use urinal and fell . 12/4/18 at 10:00 AM - .LPN entered resident bathroom noted resident with both hands on grab bar, knees in bent position .Noted outer bathroom door alarm with low tone and inner bathroom door alarm was off wall .When LPN asked (resident) how alarm got in floor states, 'I tore that off' . Review of the Manager Incident Review dated 12/5/18 revealed .Res has poor safety awareness, has had TBI ([MEDICAL CONDITION]) .Replaced alarm on top of door frame. Observation of the nursing station, directly across from Resident #3's room, on 1/9/18 at 2:02 PM revealed 2 LPN's and 4 CNA's in the immediate area of the nursing station. Observation included the sounding of Resident #3's bathroom alarm for approximately 1-2 minutes before 1 (#1) of the 4 CNA's in the immediate area responded to the bathroom alarm. Observation of the resident and the resident's room on 1/9/18 at 2:05 PM revealed CNA #1 had transferred Resident #3 from the commode in the bathroom and was wheeling him back to bed. Observation revealed 2 alarms present at the top of the bathroom door casing, 1 on the inside of the door and 1 on the casing. Observation continued and revealed the first alarm placed on the door casing was not working. Observation of the alarm, after it was turned back on, revealed a soft chirping sound. Interview with CNA #1 on 1/9/18 at 2:07 PM, in the resident's room, revealed she stated the alarm had been turned off by her as the resident was being assisted. Interview with CNA #2 on 1/9/18 at 2:10 PM at the nursing station, revealed there was a louder sound alternative for the chirping alarm placed on the resident's bathroom door casing and stated, I put the alarm on the louder sound when I am working . Interview with the Rehabilitation (Rehab) Director on 1/9/18 at 2:15 PM, in the conference room, revealed Resident #3 was treated by P.T. and O.T. (Occupational Therapy) from admission in (MONTH) until 7/11/18. Continued interview confirmed the resident was treated by P.T. for a second period from 9/5/18-11/13/18. Further interview revealed the second treatment period focused on transfers and balance and the therapy department determined the resident was not safe for independent use of a hemi-walker. Further interview revealed the Rehab Director participated in the interdisciplinary meetings to address falls. Interview continued, with concurrent review of rehab screening tools provided, and confirmed the intervention of replacing the resident's water pitcher, developed on 11/19/18, did not address the circumstances of the 11/18/18 fall. Interview with the MDS Registered Nurse (RN) on 1/9/18 at 2:55 PM, in the conference room, included the question of whether providing the resident with a lighter water pitcher addressed the 11/18/18 fall, and the RN responded, It has gotten harder to come up with an intervention . Interview with the Administrator on 1/9/18 at 3:20 PM, in his office, confirmed the facility continued to have difficulty with battery checks and replacement when he arrived 3 weeks prior. Interview with the DON on 1/9/18 at 4:05 PM, in the conference room, revealed 7 of the investigations for the root cause of Resident #3's 11 falls concluded the root cause was due to the resident's cognition. Interview continued and the DON stated I will have to review them. In conclusion, 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aide in the development of an intervention to create a safer environment. Review revealed 7 intervention developed did not address the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room.",2020-09-01
395,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2019-01-09,865,D,0,1,DWFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Provider History Profile Review, medical record review, and interview the facility failed to provide an effective Quality Assurance Performance Improvement Program (QAPI) to ensure care plan interventions were effective, re-evaluate the effectiveness of care plan interventions after each resident fall, and consistently identify the root cause analysis of falls. The QAPI program failed to effectively evaluate, recognize, and monitor falls to ensure the QAPI program was effective in the prevention of repeat deficiencies at F-689 and F-865 (formerly at F-323 and F-520) affecting 1 resident (#3) of 4 residents reviewed for fall of 21 residents reviewed. The findings include: Review of the facility policy, Quality Assurance Performance Improvement, with a copyright date of 2014 revealed .Our Quality Assurance and Performance Improvement Program .represent our facility's commitment to continuous quality improvement .The program ensures a systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our performance goals .The QAPI committee's oversight responsibilities shall include, but not limited to the following .Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to .medical record review, fall log, incident and accident reports, quality measures, survey outcomes .The QAPI Committee will review the plan annually and make the necessary revisions, Revisions shall reflect the findings, discussions, meetings, surveys, interaction with executive leadership .of the previous year . Review of the Provider History Profile dated 12/2016 revealed the facility was cited at F-323 at a Harm level during the annual Recertification survey on 12/14/16 for failure to ensure a resident was free from accidents resulting in injury. Review of the Provider History Profile dated 11/2017 revealed the facility was cited at F-323 and F-520 at an [NAME] pattern level during the annual Recertification survey on 11/13/17 for failure to complete a thorough investigation of falls, failure to provide supervision for residents to prevent falls, and failure to implement interventions to prevent falls. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Medical record review revealed the facility failed to consistently identify and investigate the root cause of Resident #3's falls. Further review revealed the facility failed to create effective interventions to prevent falls. Medical record review of the facility's documentation revealed 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aid in the development of an intervention for creating a safer environment. Review revealed 7 interventions developed had not addressed the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room. Interview with the Administrator on 01/9/19 at 3:44 PM, in the Administrator's office, confirmed the facility had a repeat deficiency of F-323 on 12/14/16 at a harm level during an annual recertification survey. Continued interview confirmed the facility had a repeat deficiencies of F-323 and F-520 on 11/13/17 during the annual recertification survey related to falls and QAPI. Further interview confirmed the QAPI Committee failed to conduct a thorough and consistent root cause analysis on the facility's resident falls and failed to effectively evaluate, recognize, and monitor their system for managing resident's falls to prevent repeat deficiencies. Further interview confirmed the facility's QAPI program failed to adhere to and follow their policy related to falls to prevent repeat deficiencies related to falls.",2020-09-01
396,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2020-02-25,656,D,0,1,HQTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 Resident (#61) of 3 residents reviewed for [MEDICAL TREATMENT]. The findings include: Review of medical record review showed Resident #61 was admitted on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan, updated 12/23/2019, showed the resident had [MEDICAL CONDITION] and the potential for complications related to [MEDICAL TREATMENT]. The care plan did not address Resident #61's type of [MEDICAL TREATMENT] access or the location of the access site. Interview Assistant Minimum Data Set (MDS) Coordinator on 2/24/2020 at 2:00 PM, stated Resident #61's care plan was to address the type of [MEDICAL TREATMENT] access and where the access site was located. The resident's care plan does not address the type of [MEDICAL TREATMENT] access or the location of the access site.",2020-09-01
397,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2020-02-25,695,D,0,1,HQTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview, the facility failed to change oxygen tubing and replace humidifier bottles for 2 residents (#60 and #72) of 8 residents reviewed for oxygen use. The findings included: Review of the facility policy titled, O2, (Oxygen) undated, showed .Tubing, humidifier bottles and filters will be changed, cleaned and maintained by the facility . Review of the medical record, showed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 4/11/2019, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 10:50 AM, showed Resident #60 was wearing oxygen at 3 LPM via nasal cannula and the tubing and water bottle for humidification was dated 2/13/2020. During an interview conducted on 2/23/2020 at 10:50 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident's #60's tubing and humidification bottle was dated 2/13/2020, was to be changed weekly, and had not been changed in a timely manner. Review of the medical record, showed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Recapitulation Orders for (MONTH) 2020, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 9:00 AM, showed Resident #72 wearing oxygen via nasal cannula, oxygen tube dated 1/5/2020, and water bottle for humidification was empty and dated 1/5/2020. During an interview conducted on 2/23/2020 at 9:31 AM, LPN #1, who was assigned to care for Resident #72, stated oxygen tubing is supposed to be changed weekly and the residents tubing had not been changed since the 5th (1/5/2020) and .she's out of water too (humidifier bottle empty and dated 1/5/2020) . During an interview conducted on 2/25/2020 at 9:09 AM, Director of Nursing (DON) confirmed the water bottle used for humidification should have been replaced if it was empty and the oxygen tubing should have been changed.",2020-09-01
398,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,252,D,1,0,RIJH11,"> Based on facility policy review, observation, and interview the facility failed to maintain a homelike environment by eliminating odors in 1 of 2 Television rooms observed in 5 of 5 observations. The findings included: Review of the facility policy, Day Room and Lounge Cleaning, not dated revealed .clean and sanitary, neat appearing and odor-free day rooms and lounges . Observation on 7/10/17 at 11:00 AM, in the South TV room revealed a foul odor, 8 residents present and unable to determine if the odor was related to a particular resident. Observation on 7/10/17 at 12:30 PM, revealed a foul odor present in the South TV room. Observation of the South wing on 7/10/17 at 7:50 PM, revealed a strong foul odor was present in the South wing TV room. Observation/Interview with LPN on 7/10/17 at 8:55 PM, in the South wing TV room confirmed the room had a foul odor described by LPN as an old urine smell. Interview with Director of Environmental Services on 7/11/17 at 10:48 AM, in the South TV room confirmed the room had a foul odor. Further interview revealed the staff had shampooed the carpet 7/10/17 PM, and the upholstery was cleaned 7/11/17 AM.",2020-09-01
399,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,312,D,1,0,RIJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's policy, medical record review, observation and interview, the facility failed to provide nail care for 1 resident (#1) of 4 residents reviewed. The findings included: Review of the facility policy, Infection Control-Fingernail Maintenance not dated revealed .Necessary attention will be given to residents fingernails to maintain cleanliness as needed .Fingernails should be kept clean .clinical staff will provide fingernail care as necessary . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored 3 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment, and required extensive assistance for personal hygiene. Observation on 7/10/17 at 12:51 PM, of Resident #1 in the dining room revealed the resident seated at a dining table in a wheel chair. The resident was feeding himself; bilateral hands were observed with dark present on the right hand under the thumbnail and fingernails. Observation of Resident #1 on 7/10/17 at 7:45 PM, in the resident's room revealed his fingers and thumb nails on his right hand with thick dark debris underneath the nails. Interview with Registered Nurse Assistant Director of Nursing (ADON) on 7/10/17 at 7:50 PM, at the North wing nursing station revealed nail care is to be done during showers, or during a bed bath. Observation/Interview with Licensed Practical Nurse on 7/10/17 at 8:25 PM, in Resident #1's room confirmed the resident's fingernails and thumb nail on his right hand had dark thick debris underneath the nails. Further interview confirmed the resident had not received nail care as he should have.",2020-09-01
400,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,157,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician and family of a fall for 1 resident (#43) of 8 residents reviewed for falls, of 29 residents reviewed. The findings included: Medical record review revealed Resident #43 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 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review of a nursing note dated 9/15/17 at 8:45 PM revealed, .Night nurse here for shift report. Night nurse taken to resident's room for report. Night nurse verbalizes understanding to this nurse's shift report. Resident lying on floor mat. Resident's eyes closed, respirations even and unlabored. Skin warm, dry and normal color . Medical record review of a nursing note dated 9/15/17 at 9:30 PM revealed, .This nurse and staff observe resident sitting on mat. Resident offered water per this nurse. Resident refuses to drink water. Resident covered with blanket for comfort. This nurse leaves room with door open due to no residents in hallway . Medical record review of the SBAR - Change of Condition (Situation, Background, Action, Response) created on 9/16/17 at 12:14 AM with an effective date (meaning the time/date of incident) of 9:07 PM, revealed, .Resident observed sitting on floor in her room. Resident was scooting across floor . Medical record review of a nursing noted dated 9/16/17 at 7:32 AM revealed, .Post Fall: Head to toe assessment - greyish/blue colored bruise & (and) swelling across forehead - tissue soft to palpate .Quarter size blue bruise with raised area top of head. Bruise remains bridge of nose; swelling with reddish bruise lt (left) eye. Old bruising both hands & scattered bruises BUE & BLE (bilateral upper extremities and bilateral lower extremities) .Bruise rt (right) side rib area. No c/o (complaint of) pain. Rested quietly during the night in low bed - mattress beside bed . Medical record review of a nursing note dated 9/16/17 at 6:39 PM revealed, .Notified of increase in bruising and [MEDICAL CONDITION] to the nose, forehead, and eyes of this resident S/P (after) fall last night. Spoke with the hospice medical director .Medical director for hospice at this time wants to wait for the hospice nurse to evaluate the resident and speak with the family on their wishes . Medical record review of a nursing note dated 9/16/17 at 7:50 PM revealed, .Talked with D.O.N. (Director of Nursing) regarding resident previous fall. Hospice called and nurse came in .Asked to call family to see if they wanted to send resident to ER (emergency room ) or not .Talked with (family member) . Interview with Registered Nurse (RN) #1 on 11/7/17, at 8:04 AM, at the south nurses' station, revealed RN #1 was notified of Resident #43's facial bruising on 9/16/17, at approximately 6:30 PM, approximately 21 1/2 hours after the fall. The RN then notified the hospice physician and family at that time. Further interview confirmed the facility failed to notify the physician and family of the fall in a timely manner.",2020-09-01
401,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,224,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, review of police report, and interview, the facility failed to ensure 1 resident (#101) was free from misappropriation of property of 3 residents reviewed for abuse of 29 sampled residents. The findings included: Review of the facility policy Abuse Prevention Program, updated 1/19/17, revealed .prevent resident abuse .theft .misappropriation of resident property .the deliberate .use of a resident's belongings or money without the resident's consent . Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #101 had a Brief Interview for Mental Status score of 12, indicating the resident was minimally cognitively impaired. Continued review revealed no behavioral symptoms, hallucinations or delusions and the resident was independent with activities of daily living. Review of a facility investigation revealed Resident #101's daughter discovered several charges to the resident's bank account she believed to be fraudulent and reported the suspicious charges to the facility on [DATE]. Review of Resident #101's Bank Statement dated 8/18/17 revealed a check charge in the amount of $309.15, along with several other charges totaling approximately $1,439. Review of a police report dated 8/18/17 revealed an officer of the local police department interviewed Resident #101 at the facility. Continued review revealed the resident told the officer she kept several checks in a bottom drawer in her room and she did not give permission to anyone to use them. Further review revealed, through the officer's investigation, it was discovered Certified Nursing Assistant (CNA) #5 was identified through surveillance footage to be the person writing the stolen check at a local store. Review of CNA #5's signed statement dated 8/18/17 revealed the CNA confirmed she stole a check from Resident #101 without her consent and used the funds for her own purpose. Interview with Resident #101 on 11/6/17 at 9:40 AM, in the resident's room, confirmed she had been .robbed .a few months ago . Interview with the Administrator on 11/8/17 at 11:44 AM, in the Director of Nursing office, confirmed the facility failed to prevent the misappropriation of property for Resident #101.",2020-09-01
402,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,278,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 (#21) resident of 29 residents reviewed. The findings included: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed the MDS assessment did not indicate the resident was missing any teeth. Observation of the resident on 11/8/17 at 10:10 AM, revealed the resident ambulating in the hall. Continued observation revealed the resident had no natural teeth. Interview with Registered Nurse (RN) MDS Coordinator on 11/8/17 at 4:45 PM, at the nursing station, confirmed the Annual MDS dated [DATE] was inaccurate related to the dental status.",2020-09-01
404,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,314,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, interview, and observation, the facility failed to ensure weekly skin assessments were completed for 2 (#30, #106) residents of 5 residents reviewed for pressure ulcers of 29 residents reviewed. The findings included: Review of the facility policy, Skin Integrity Guideline, undated, revealed .Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Braden Scale dated 8/16/17 revealed .score 13.0 .moderate risk . Medical record review of the Weekly Skin Review dated 8/21/17 revealed .elbows and heels clear . Medical record review of the Weekly Skin Review dated 9/4/17 revealed .Treatment in progress for wounds to coccyx and right hip .Top of right foot, red nonblanchable area 3 (centimeters) x (by) 2 (centimeters) .and purple nonblanchable area to bottom of left heel . Medical record review of a Physician's Order dated 9/4/17 revealed .Apply skin prep to red area to top of right foot Q (every) shift until healed .red non blanchable area .apply skin prep to left heel Q shift .for purple non blanchable area . Medical record review of a Physician's Progress Note dated 9/5/17 revealed .area red and nonblanchable on the top of his right foot and a purple discolored area on the bottom of his heel .he said that he often crosses his feet and he feels like this is what has happened . Medical record review of the Progress Note dated 9/12/17 revealed .Right dorsal foot 2.0 (cm) x 2.4 (cm) unblanchable red area .left foot is 2.0 (cm) x 2.0 (cm) red area now nonblanchable appearing now since initial onset which appeared more bruise in appearance. Skin prep continues . Medical record review of the Progress Notes dated 9/16/17 revealed .Resident .refuses to turn and reposition. Resident request that his feet be placed on pillows . Interview with the Wound Care Nurse on 11/8/17 at 8:20 AM, at the Nursing Station, confirmed there was no documentation a skin assessment had been performed the week of 8/28/17, prior to the identification of the red nonblanchable area to the top of the right foot and the purple area on the left heel. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 was severely cognitively impaired and required extensive assistance of two person physical assist for bed mobility, transfers, dressing, and personal hygiene, and was totally dependent of two or more physical assist for toileting. Further review revealed Resident #106 was at risk for developing a pressure ulcer, did not have a pressure ulcer at the time of the assessment, and was always incontinent of urine and bowel. Medical record review of Resident #106's plan of care dated 8/29/17 revealed .at increased risk for alteration in skin integrity .impaired mobility . Medical record review revealed a weekly skin assessment was not completed for the week of 10/8/17 - 10/14/17. Medical record review of the weekly skin sheet dated 10/16/17 revealed .open areas .R (right) lateral (side) ankle 1.8 (cm) x 1.6 (cm) x 0.8 (cm) .yellow slough (devitalized tissue) . Medical record review of the Wound report dated 10/27/17 revealed .right ankle .granulation noted to edges of wound with white slough in center .pressure ulcer .unstageable .size of wound .1.9 (cm) x 1.9 . Interview with Registered Nurse (RN) #1 on 11/8/17 at 11:01 AM, in the nursing office, confirmed the facility failed to complete a weekly skin assessment on Resident #106 the week of 10/8/17 - 10/14/17. Interview with Nurse Practitioner (NP) #1 on 11/9/17 at 1:49 PM, in the conference room, confirmed due to the resident's overall condition the development of a pressure ulcer was unavoidable. Observation of Resident #106's right ankle wound on 11/9/17 at 3:42 PM, with RN #1, Licensed Practical Nurse #1, and NP #1 in the resident's room revealed Resident #106 was lying in bed on an air mattress. Continued observation revealed an open area to the right outer ankle approximately the size of a quarter. Further observation revealed the wound bed was red with pink edges. Continued observation revealed RN #1 obtained measurements of the wound which were 2.5 centimeters (cm) x 2.5 cm x 0.5 cm.",2020-09-01
406,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,329,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to attempt to taper an antidepressant medication for 1 resident (#59) of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility Order Recap Report dated 5/1/17 through 11/30/17 revealed .[MEDICATION NAME] (antidepressant medication) .give 20 mg (milligrams) .at bedtimefor depression .start date .8/5/16 .end date .11/13/17 Medical record review of the Consultant Communication to the Physician dated 6/2017 revealed .Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Agents .[MEDICATION NAME] 20 mg hs (at bedtime) . Continued review revealed no response from the physician. Medical record review revealed Resident #59 remained on the initial dose of [MEDICATION NAME] from 8/5/16 until 11/13/17 without documentation from the facility's physician why a reduction would be contraindicated. Interview with the Director of Nursing (DON) on 11/13/17 at 1:00 PM, in the DON's office, confirmed the facility failed to document a clinical rationale for the continuation of a psychtropic medication by the facility's physician, failed to attempt to taper a [MEDICAL CONDITION] medication, and failed to ensure the resident was free from an unnecessary medication.",2020-09-01
408,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,428,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to act on a pharmacy recommendation for an antidepressant gradual dose reduction (GDR) for 1 Resident (#59) of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #59's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident was severely cognitively impaired. Medical record review of the facility Order Recap Report dated 5/1/17 through 11/30/17 revealed .Celexa (antidepressant) .give 20 mg (milligrams) .at bedtime for depression .start date .08/05/2016 . Medical record review of the pharmacist Consultant Communication to the Physician dated 6/2017 revealed .Gradual Dose Reduction for Psychotropic Agents .Celexa 20 mg hs (at bedtime) . Continued review revealed no physician response to the recommendation from the pharmacist. Interview with the Administrator on 11/7/17 at 2:30 PM, in the conference room, confirmed the facility failed to respond to a recommendation from the pharmacist.",2020-09-01
410,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-03-01,223,D,0,1,AQIZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to prevent resident verbal abuse for 1 resident (#193) of 3 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, Neglect and Misappropriation of Property, revealed .It is .policy to prevent the occurrence of abuse .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .or within their hearing distance, regardless of age, ability to comprehend, or disability . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #193 had moderately impaired cognitive skills, had adequate hearing and clear speech, and could make himself understood and understood others. Review of facility documentation dated 12/28/16 at 1:20 PM revealed Licensed Practical Nurse (LPN) #8 was witnessed by Housekeeper #1 and Certified Nurse Aide (CNA) #6 calling Resident #193 inappropriate names. Continued review of the facility documentation revealed LPN #8 stated she was . burned out .I had reached my limit . and she confirmed she called Resident #193 inappropriate names. Review of the Witness Statement by CNA #6 dated 12/28/16 revealed LPN #8 .come up the hall and said He's a dick head as (and} yes I said it out loud . Review of the Witness Statement by Housekeeper #1 dated 12/9/16 revealed Resident #193 .said she (LPN #8) called him a son-of-a-[***] , she (LPN #8) looked back at him and told him God told her to do that . Review of LPN #8's employee record revealed she was hired on 11/29/16, and had passed the abuse registry verification and the background verification. Further review revealed LPN #8 had completed orientation including abuse training. Review of the work schedule for LPN #8 revealed 4 days of working with another LPN on 12/5, 12/6, 12/8, and 12/9/16. LPN #8 worked independently on 12/12, 12/14, 12/17, 12/18, 12/19, 12/22, 12/23 and 12/28/16. LPN #8 was scheduled to work and called out on 12/7, 12/13, 12/25, and 12/26/16. Interview with Resident #193 on 2/27/17 at 2:18 PM in the resident's room, when asked if anyone in the facility had abused him, revealed .a nurse cussing him and she was fired . Telephone interview with Housekeeper #1 on 2/28/17 at 2:26 PM revealed she had overheard Resident #193 and LPN #8 talking in the resident's room doorway and the . LPN was getting mad at him and was rolling her eyes . when the resident stated to the LPN .Yes you did call me a son-of-a-[***] . Further interview revealed the LPN stated .God told her to say it . as she walked away from the resident. Telephone interview with CNA #1 on 2/28/17 at 2:35 PM revealed she had overheard LPN #8 yelled at and cuss at .Resident #193 .said he was a son-of-a-[***] and then said he was a dick head as she (LPN #8) started to walk to the nursing station .she looked back down the hall and said Yes I just said that out loud . Telephone interview with CNA #3 on 2/28/17 at 2:46 PM revealed the CNA overheard a loud exchange between LPN #8 and Resident #193 but could not hear what was said. CNA #3 reported to LPN #2, seated at nursing station, of overhearing a loud exchange. The CNA stated LPN #2 went to LPN #8. Telephone interview with LPN #2 on 2/28/17 at 3:07 PM revealed CNA #3 came to her and told LPN #2 she was needed down the hall .something was said . Further interview revealed LPN #2 went to LPN #8, at the medicine cart in the hallway, and LPN #8 stated Resident #193 had cussed at LPN #8. LPN #2 went to check on Resident #193 who told LPN #2 that LPN #8 had cussed at him. Further interview revealed the resident was monitored by a CNA while LPN #8 was escorted to the ADON/RN #1 office. Interview with ADON/RN#1 on 3/1/17 at 8:40 AM in the chapel revealed LPN #2 reported to the ADON/RN #1 about LPN #8 being heard calling Resident #193 inappropriate names. Further interview revealed LPN #8 was brought to the ADON/RN #1's office and was informed the LPN was overheard calling Resident #193 inappropriate names. Further interview revealed LPN #8 confirmed she had called the resident inappropriate names. Further interview revealed LPN #8 was escorted to the Director of Nursing's (DON's) office where the allegation was discussed and LPN #8 confirmed she had called the resident a name and knew what she had done was not appropriate. Interview with CNA #6 on 3/1/17 at 9:19 AM in the chapel revealed she was in the hallway and had heard LPN #8 .say he's (Resident #193) a dick head and Yes I said that out loud . Further interview revealed the CNA went to the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #1 to report the event when a staff member (unable to recall who) entered the RN's office to report the exchange between LPN #8 and the resident. Interview with the DON on 3/1/17 at 9:31 AM in the DON's office revealed the ADON/RN #1 informed the DON there was a situation involving LPN #8 and the LPN was escorted to the DON's office. Further interview revealed the DON, ADON/RN #1 and LPN #8 discussed what had been overheard and LPN #8 confirmed she had called Resident #193 inappropriate names, she knew it was wrong to do and was embarrassed. Further interview revealed LPN #8 stated she was burned out and wanted to leave . Further interview revealed the LPN was informed her employment was terminated and was escorted off the property.",2020-09-01
412,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-04-25,655,D,0,1,VOWX11,"**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 develop and implement a baseline care plan for the care and maintenance of a peripherally inserted central catheter (PICC) for 1 resident (Resident #250) of 1 residents reviewed for PICC lines of 30 residents reviewed. The findings included: Review of the facility policy Baseline Plan of Care, not dated, revealed .development and implementation of the Baseline plan of care will start at admission and within the first 48 hours .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .goals based on admission orders [REDACTED]. Medical record review revealed Resident #250 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #250 was admitted to the facility with a PICC line in the right upper extremity. Medical record review of the Baseline Admission Care Plan dated 4/18/18 revealed no care plan for care and maintenance of the PICC line. Observation of Resident #250 on 04/23/18 at 2:43 PM, in the resident's room, revealed a PICC line in the resident's right upper arm. Interview with the Director of Nursing on 4/24/18 at 5:09 PM, in the conference room, confirmed the facility failed to develop a baseline care plan to address the care and maintenance for Resident #250's PICC line.",2020-09-01
413,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-08-22,761,D,1,0,JFHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observations, and interviews, the facility failed to ensure narcotics were stored under lock and key for one resident (#8) of 8 residents reviewed for medication storage and failed to follow procedures during narcotic reconciliation on 1 of 5 medication carts on 1 of 5 wings of the facility observed for narcotic reconciliation. The findings included: Review of facility policy Controlled Medication and Drug Diversion, last revised 7/24/18, revealed .2. At each shift change or when keys are rendered a physical inventory of all controlled medication is conducted by two staff .this is completed as follows .a. the nurse .surrendering the keys will read from the controlled substance accountability book the name of the resident and the medications to be accounted .oncoming nurse .will locate the medication .count the remaining medication and report .the amount of medication remaining .6. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until .destroyed by the facility's director of nursing, administrator, and consultant pharmacist . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home 8/1/18. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (narcotic) .10 (milligrams) .give one tablet by mouth four times a day as needed .pain . Interview with the Assistant Director of Nursing (ADON) on 8/20/18 at 2:30 PM, in the chapel, revealed on the evening of 8/1/18 she was given Resident #8's [MEDICATION NAME] for destruction by Licensed Practical Nurse (LPN #3), who had removed them from the medication cart after Resident #8 was discharged . Continued interview revealed the ADON did not immediately secure the narcotics in the secure medication storage lock box, but instead placed them in an unlocked desk drawer in her unlocked office and on 8/3/18 when the ADON attempted to retrieve the [MEDICATION NAME], the narcotics were missing from the desk drawer. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to secure Resident #8's discontinued narcotics under lock and key in a secure area and failed to follow facility policy. Observation of a narcotic drug reconciliation (narcotic count) with LPN #8 and LPN #9 on 8/21/18 at 12:03 AM, of the D wing medication cart, revealed LPN #8 and LPN #9 completed the narcotic count without naming the resident or the name of each narcotic and did not simultaneously verify the remaining quantity of each narcotic medication compared to the narcotic inventory control card. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to ensure narcotics were verified and reconciled during a narcotic count and the facility failed to follow facility policy.",2020-09-01
414,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-09-27,241,D,1,0,QHMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and staff interview, the facility failed to provide dignity covers for catheter bags for 2 (Resident #3 and Resident #10) of 3 sampled residents. This had the potential to affect all 15 residents who had catheters. Failure to provide dignity covers for catheter drainage bags had the potential to demean patients. The findings included: Review of the facility's policy titled, Catherization Care, revised of 9/7/17, indicated, .13. Routinely check to ensure .Drainage bag is covered with a privacy cover unless resident requests otherwise. 1. Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 12:00 PM, Resident #3 was observed eating lunch in room [ROOM NUMBER]. The drainage bag for the catheter was attached to the bed. The catheter drainage bag which had approximately 300 cubic centimeters (cc) of urine was visible and did not have a dignity cover on it. 2. On 9/25/17 at 1:30 PM, Resident #10 was observed lying in his bed in room [ROOM NUMBER]. The drainage bag for the catheter which was observed hanging on the bed with approximately 200 cc's of urine was visible without a dignity cover. During an interview on 9/25/17 at 12:30 PM, on the 200 Hallway, Certified Nursing Assistant #1 confirmed the drainage bag for the catheter should have a cover over it. During an interview on 9/25/17 at 2:40 PM, in the conference room, the Director of Nursing (DON) stated all catheter drainage bags should have a dignity cover on them. The DON further stated the facility has ordered new dignity bags for the catheter drainage bags and the facility is currently using pillowcases to cover the catheter drainage bags until the new dignity bags arrive.",2020-09-01
418,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,677,D,0,1,2LOM11,"**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 Activities of Daily Living (ADL) assistance was provided related to nail care for 1 of 4 (Resident #38) sampled residents reviewed for ADL care. The findings include: 1. The facility's undated Policy and Procedure Foot Care policy documented, .Purpose .To ensure that residents receive appropriate care and services to maintain health and hygiene of their feet. To ensure that residents feet are inspected on a regular basis . The facility's undated NAIL CARE policy, documented, .It is the policy of the facility to provide personal hygiene needs and to promote health, safety and the prevention of infection. This includes clean, smooth nails at a well-groomed safe length acceptable to the resident . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 had a score of 9 on the Brief Interview of Mental Status (BIMS), which indicated moderate cognitive impairment, and required extensive assistance for ADL care. Interview with Resident #38's family member on 3/11/19 at 1:40 PM in Resident #38's room, the family member stated, They aren't trimming his toenails . Observation and interview in Resident #38's room with the Family Nurse Practitioner (FNP) on 3/12/19 at 1:46 PM, revealed Resident #38 had jagged toenails on the toes of his right foot, a long jagged toenail on the left great toe, and long toenails on the remaining toes of his left foot. The FNP inspected Resident #38's toenails on both feet and stated, .couple (on the right foot) need to be filed .(toenail on the left great toe) is jagged and a couple (toenails) need to be cut . Interview with the Director of Nursing (DON) on 3/13/19 at 12:10 PM, in the Conference Room, the DON was asked if it was important for residents in the facility to receive nail care. The DON stated, It's very important. The DON confirmed it was acceptable for CNA's and nurses to assess, trim and file toenails.",2020-09-01
421,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,698,D,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, contractual agreement, medical record review, and interview, the facility failed to provide appropriate [MEDICAL TREATMENT] care and services for 1 of 1 (Resident #28) sampled residents reviewed for [MEDICAL TREATMENT]. The findings included: 1. The facility's undated Community [MEDICAL TREATMENT] policy documented, .The facility will obtain orders from the physician for the resident [MEDICAL TREATMENT] days which will be written on the physician order [REDACTED].bleeding from the [MEDICAL TREATMENT] . The facility's undated Assessment of Arterio Venus (Arteriovenous) Shunts, Fistulas & (and) Grafts policy documented, .It is the policy of this facility to evaluate arterio venous shunts, fistulas and grafts by a licensed nurse to facilitate early detection of potential complications which include signs and symptoms of infection, leakage or [MEDICAL CONDITION] .Document Completion of assessment on proper form or TAR (Treatment Administration Record) . 2. The facility's SNF (Skilled Nursing Facility) OUTPATIENT [MEDICAL TREATMENT] SERVICES AGREEMENT dated 1/21/19 documented, .Interchange of Information .The Nursing Facility Shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) Residents, including a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of Services to the [MEDICAL CONDITION] Residents .Collaboration of Care .Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit . 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] and 30 day assessment dated [DATE] documented the resident received [MEDICAL TREATMENT]. The care plan for Resident #28 dated 2/5/19 documented, .The resident is in [MEDICAL CONDITION] & receives [MEDICAL TREATMENT] treatment and management .M (Monday)-W (Wednesday)-F (Friday) at (Named [MEDICAL TREATMENT] Clinic) .interventions .Monitor Access site for abnormal bleeding and/or Signs and Symptoms of Infection. Review of the physician's orders [REDACTED].#28 to receive [MEDICAL TREATMENT] services. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form for Resident #28 dated 2/15/19, 3/1/19 and 3/11/19 revealed the facility failed to complete the pre-assessment. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form dated 2/13/19, 2/15/19, 2/18/19, 2/20/19, 2/22/19, 2/25/19, 2/27/19, 3/1/19, and 3/4/19 revealed the facility failed to complete the post assessment. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form dated 3/1/19 and 3/11/19 revealed 2 documented statements from the [MEDICAL TREATMENT] center asking the facility to complete the communication form. Interview with the Director of Nursing (DON) on 3/13/19 at 11:49 AM, in the Conference Room, the DON confirmed that there were no written physician's orders [REDACTED].",2020-09-01
422,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,812,D,0,1,2LOM11,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 2 of 13 (Certified Nursing Assistant (CNA) #1 and #2) staff members returned a potentially contaminated meal tray to the cart containing clean food trays and failed to distribute and serve food and beverages in a sanitary manner by not following the facility's hand hygiene policy. The findings include: 1. The facility's undated Hand Hygiene policy documented, .Hand hygiene is the single most efficient means of preventing the spread of infection .Hand Washing Procedure .Wet hands with warm water .Apply .soap to hands and rub hands together vigorously .Rinse hands with warm water and dry with a disposable towel .Use towel to turn off faucet . 2. Observations in Resident #27's room on 3/11/19 at 11:29 AM, revealed CNA #1 took a meal tray into the room, removed the cover from the plate and allowed Resident #27 to look at the food. Resident #27 looked at the plate of food and bent over the plate to smell the food. Resident #27 told CNA #1 she did not want it. CNA #1 carried the tray out of the room, and placed it on the meal cart with the clean trays. Interview with the Director of Nursing (DON) on 3/13/19 at 12:17 PM, in the Conference Room, the DON was asked if it was appropriate for a CNA to take a meal tray into a resident's room, remove the cover and allow the resident to smell the food, and then return that tray to the meal cart with the clean trays. The DON stated, No, Ma'am. Observations in Resident #28's room on 3/12/19 at 5:33 PM, revealed CNA #2 performed hand hygiene at the sink after delivering the meal tray to the resident and turned the faucet off with her bare hand. Observations in Resident #24's room on 3/12/19 at 5:38 PM, revealed CNA #2 performed hand hygiene at the sink after delivering the meal tray to the resident and turned the faucet off with her bare hand. Interview with the DON on 3/13/19 at 12:14 PM, in the Conference Room, the DON was asked if it was appropriate to turn off the faucet with a bare hand during hand hygiene. The DON stated, .No it is not .rinse and obtain a towel and turn the water off with the towel .",2020-09-01
424,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,842,D,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure accurate nursing documentation for 2 of 17 (Resident #15 and #38) sampled residents reviewed. The findings include: 1. The facility's undated Admission/Readmission orders [REDACTED].To ensure that all .orders provided to the facility either by the physician or physician extender is accurately documented and transcribed in the resident's medical record . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 1.2 (tube feeding) (symbol for at) 60ML(milliliters)/HR (hour) via PEG (Percutaneous Endoscopic Gastrostomy) TUBE . Review of the facility's Medication Administration Record [REDACTED]. Review of the Nursing Progress Note dated 12/3/18, 12/4/18, 12/6/18, and 12/7/18 revealed [MEDICATION NAME] 1.2 was infusing at 60 ml/hr as ordered. Interview with the Director of Nursing (DON) on 3/13/19 at 9:04 AM, in the DON office, the DON was asked if there was documentation on the (MONTH) (YEAR) MAR for the [MEDICATION NAME] 1.2 tube feeding at 60 ML/hr between 12/3/19 and 12/13/19. The DON stated, I found a few nurses notes that charted he was receiving it, but it's not documented every day. The DON was asked if it was appropriate that nurses were not documenting Resident #38 was receiving the tube feeding as ordered. The DON stated, No, it is not acceptable. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented, Discharge assessment-return anticipated . Review of Resident #15's nurses notes between 12/26/18 - 12/31/18, revealed there were no nurses notes to explain why Resident #15 was discharged to the hospital. The nurses note dated 1/1/19 documented, .re admitted ,[DATE] (12/29/18) . There were no nurses notes the first 3 days of Resident #15's readmission. Interview with the DON on 3/13/19 at 10:53 AM, at the West Nurse's Station, the DON was asked if she would expect the nurse to chart the resident's condition in the nurses notes. The DON stated, Yes. The DON was asked if there was a nurse's note when he was transferred to the hospital. The DON stated, I don't see a note.",2020-09-01
426,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,225,D,0,1,TTUW11,"**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 investigate injuries of unknown origin for 1 resident (#4) of 28 residents reviewed. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17 revealed .The nursing staff is responsible for reporting the appearance of bruises .Such reporting will be documented in the Electronic Medical Record (EMR) under the Risk Management section .V.Investigation. All incidents will be documented, whether or not abuse occurred, was alleged or suspected . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Resident required extensive assistance of 2 people for transfers and bed mobility, and extensive assistance of 1 person for eating, toileting and personal hygiene. Medical record review of the Incident Note dated 4/18/17 revealed New bruises noted to resident of unknown origin .New bruise approximately 1.5 x (by) 1.5 cm (centimeters) not3 (noted) to left side of chin. Bruise approximately 3 cm x 4 cm noted to right bicep. Bruise approximately 11 cm x 4.5 cm noted to left flank Resident unable to verbalize exactly where bruises came from . Observation on 5/7/17 at 5:26 PM in Resident #2's room revealed the Resident had a bruise to the the left forearm. Interview with Certified Nursing Aide (CNA) #5 on 5/8/17 at 1:40 PM beside the nurses station revealed the CNA was familiar with Resident #2. On or about 4/17/17 the CNA noted a bruise on Resident #2's upper lip. Continued interview revealed the CNA thought it was food however when the CNA attempted to wipe the area it did not wipe off.' Further interview revealed the CNA notifed the charge nurse. Interview with Registered Nurse (RN) #1 on 5/8/17 at 2 PM at the nurses's station revealed RN #1 was familiar with Resident #2. Continued interview revealed RN #1 did not remember the Resident having a fall in the month of April. Further interview revealed RN #1 recalled Resident #2 pulled a dresser over which hit the Resident's head and foot. The Nurse did not remember the date. Interview with the Director of Nursing (DON) on 5/9/17 at 2:36 PM outside the Administrator's office revealed the facility did not have an incident report regarding Resident #2's bruises. Continued interview with the DON confirmed the facility failed to investigate the cause of Resident #2's bruises.",2020-09-01
427,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,241,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview, the facility failed to ensure medication was administered to 1 resident (#3) in a private and dignified manner. The findings included: Review of facility policy, 5.1: Drug Administration-General Guidelines, revealed .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) is 'flagged' per facility protocol. After completing the medication pass, the nurse returns to the missed resident to administer the medication . Medical record review revealed Resident #3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/7/17 at 5:18 PM in the dining room revealed Licensed Practical Nurse (LPN #4) administered Resident #3's medication in a small plastic cup and then left the dining room after the medications were swallowed. Interview with LPN #4 on 5/7/17 at 5:58 PM at the nurse's station confirmed she administered medications to Resident #3 in the dining room. LPN #4 confirmed this was not normal practice and she generally administered medication to residents in their rooms. Interview with Director of Nursing (DON) on 5/9/17 at 4:50 PM outside the conference room confirmed medication was not to be administered in the dining room.",2020-09-01
428,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,242,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, shower schedule review, and observation, the facility failed to honor the resident's choice for showers for 1 resident (#65) and failed to honor the days for showering for 1 resident (#94) of 28 residents reviewed in the stage 2 sample. The findings included: Review of facility policy, Resident Rights revealed .Self Determination- You may choose your own activities, schedules and health care and any other aspect significant to and affecting your life within the facility . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. Continued review revealed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Interview with Resident #65 on 5/7/17 at 7:30 PM in the resident's room revealed when the resident was asked if he was able to choose between a tub bath, bed bath or shower, the resident stated No. Continued review revealed when asked if he was able to choose how many times he took a shower or bath, the resident stated, No, not really. I want a shower so I can get my head wet, but they give me a bed bath most of the time. Review of the Shower Schedule revealed Resident #65 was scheduled to receive a shower on Monday, Wednesday, and Friday each week during day shift (7:00 AM-3:00 PM). Interview with Certified Nurse Aide (CNA) #3 on 5/8/17 at 3:10 PM in the 100 Hall confirmed she was assigned to the resident regularly. Continued interview confirmed the CNA did not assist Resident #65 with a shower as scheduled. Interview with Resident #65 on 5/9/17 at 2:45 PM in the resident's room confirmed he did not receive a shower on Monday 5/8/17. Continued interview revealed the resident stated he asked for a shower 3 different times during the afternoon and evening and was told he would receive a shower that evening, but did not. Interview with the Director of Nursing (DON) on 5/9/17 at 3:30 PM in the Administrator's Office confirmed Resident #65 did not receive a shower per his choice and the shower schedule. The DON confirmed the facility failed to honor the resident's choice for showering. Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day MDS dated [DATE] revealed Resident #94 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Resident #94 required extensive assistance of 2 persons for bed mobility, and assistance of 1 person for transfers, dressing, eating, toileting, and personal hygiene. Review of a Psychosocial Well-Being assessment dated [DATE] revealed Resident #94's choice was for a shower bath in the mornings on a Tuesday, Thursday, and Saturday schedule. Observation on 5/7/17 at 4:07 PM in Resident #94's room revealed the Resident lying in bed wearing a hospital gown, able to respond to yes-no questions but unable to respond to complex questions such as how was your meal? Phone interview with a family member on 5/8/17 at 9:40 AM revealed the family member visits daily. Further interview revealed Resident #94 was in a state of mental and physical decline when the Resident was admitted to the facility and was unable to communicate choices. However the family member notified the staff the Resident showered daily at 6:00 AM when at home. Continued interview revealed the Resident had a bed bath on Wednesday 5/3/17 and had not received a shower since then. Interview with CNA #5 on 5/8/17 at 1:40 PM at the nurse's station revealed the facility did not have a process for communicating residents' choices for baths to CNAs. Continued interview revealed the CNA was not aware of Resident #94's shower choice. Interview with Resident #94 on 5/9/17 at 1:27 PM in the Resident's room revealed the Resident had a bed bath today, but preferred a shower. Interview with Licensed Practical Nurse (LPN) #1 on 5/9/17 at 1:35 PM at the nurse's station revealed the nurse was unaware of a facility process that ensured Certified Nursing Aides (CNAs) gave residents showers according to the Residents' choices. Interview with CNA #5 on 5/9/17 at 2:48 PM in the hallway in front of the linen closet revealed Resident #94 was on a Monday, Wednesday, and Friday shower schedule. Continued interview revealed Resident #94 received a bed bath instead of a shower. Interview with the DON on 5/9/17 at 2:36 PM at the unused nurse's station revealed the facilty expected residents' choices for Tuesday, Thursday, and Saturday bathing to be honored. Continued interview revealed the facility expected staff to honor residents' choice for showers in place of baths. Further interview revealed the facility expected staff to give residents' baths daily if that was the Residents' choice. The DON confirmed that the facility lacked a process for ensuring CNA's gave the Resident's showers according to the Residents' choice.",2020-09-01
429,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,278,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately reflect the resident's status for 1 resident (#28) of 28 residents reviewed. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed no functional impairments for upper extremities or lower extremities. Medical record review of an Occupational Therapy Plan of Care dated 4/14/17 revealed .right forearm supination limited to 20 degrees . and a Physical Therapy Plan of care dated 12/21/16 .bilateral plantarflexion joint contractures . Observation of Resident #28 on 5/8/17 at 8:34 AM in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. All functional impairments were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with Physical Therapy Assistant (PTA #1) on 5/9/17 at 1:20 PM in the therapy department confirmed Resident #28 has bilateral foot drop. Interview with Registered Nurse (RN #2), MDS Coordinator and Restorative Nursing Program Director on 5/9/17 at 2:34 PM at the east wing nurse's station confirmed the facility failed to accurately assess the resident's functional status for her upper and lower extremities on the Quarterly MDS.",2020-09-01
430,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,281,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide services to meet professional standards for 2 Residents (#28, #80) of 5 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16, revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 RNP (Restorative Nurse Program) staff and 3 FMP (Functional Maintenance Program) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review, revealed 0 days of splint or brace assistance. Medical record review of an Occupational Therpapy Plan of Care dated 4/4/17 revealed, Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #28 on 5/8/17 at 8:34 AM in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 8:43 AM at the west hall nurse station reported Resident #28 was not in the RNP program. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director, on 5/09/17 at 2:34 PM at the east wing nursing station confirmed the facility failed to provide follow up ROM exercises in either of the RNP or the FMP. Resident #80 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Orders dated 5/2017 revealed [MEDICATION NAME] tablet 25 milligram (mg), give 1 tablet by mouth 2 times a day, [MEDICATION NAME] tablet 20mg, 1 tablet by mouth daily, and [MEDICATION NAME] 0.5mg every 8 hours as related to Dementia with behavioral disturbances. Medical record review of the Physicians Orders revealed no order to monitor side effects of [MEDICAL CONDITION] medications for Resident #80. Medical record review of the Medication Administration Records (MAR) dated 12/2017 - 5/2017 revealed no order for monitoring side effects for [MEDICAL CONDITION] medications for Resident #80. Interview with the Director of Nursing on 5/9/17 at 7:37 AM in the Administrator's office confirmed the facility had failed to obtain an order to monitor side effects of [MEDICAL CONDITION] medications for Resident #80.",2020-09-01
431,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,282,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to monitor and document behaviors for [MEDICAL CONDITION] drug use for 1 Resident (#39) of 5 Residents reviewed for [MEDICAL CONDITION] drug use. The findings included: Review of facility policy, Behavior Management Guideline, revised date of 3/30/16 revealed .The Director of Nursing Service/designee coordinated inservice education to all nursing staff related to behavior management .Documentation requirements . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].with Severe Psychotic Features. Medical record review of the Medication Administration Record (MAR) dated 2/2017 - 5/8/17 revealed the resident recieved the following [MEDICAL CONDITION] medications: [MEDICATION NAME] Sodium (antidepressant), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (antianxiety). Review of the care plan dated 03/20/17 revealed .behaviors which include aggressive behaviors towards others .Interventions .monitor for target behaviors/symptoms of paranoia and delusional thinking and document . Medical record review revealed no documentation of monitoring for behaviors with the use of [MEDICAL CONDITION] medications since 4/2016. Interview with Licenced Practical Nurse (LPN #1) on 5/9/17 at 8:37 AM at the nurses station revealed the monitoring of behaviors was to be documented on the MAR. Continued interview confirmed no monitoring of behaviors had been documented on the MAR from 2/1/2017-5/8/17. Continued interview confirmed an order to discontinue behavior monitoring for antipsychotic and antianxiety medications on 4/14/16. Continued interview revealed LPN #1 was not sure why the order for behavior monitoring was discontinued. When asked if monitoring for behaviors had been completed and documented since 4/14/16, LPN #1 responded I guess not. LPN #1 confirmed the facility failed to monitor and document behaviors for [MEDICAL CONDITION] drug use for Resident #39. Interview with the Director of Nursing on 5/9/17 at 11:57 AM in the conference room revealed licensed staff are expected to document behaviors for residents receiving [MEDICAL CONDITION] medications on the MAR. Continued interview confirmed the facility failed to document behaviors for Resident #39.",2020-09-01
432,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,317,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a reduction in range of motion for 1 resident (#28) of 3 residents reviewed for range of motion. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16 revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 Restorative Nurse Program (RNP) staff and 3 Functional Maintenance Program (FMP) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review revealed 0 days of splint or brace assistance. Medical record review of Occupational Therapy Plan dated 4/4/17 revealed Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #28 on 5/8/17 at 8:34 AM, in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 4:40 PM revealed this resident did not have foot drop at the time of admission. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director on 5/09/17 at 2:34 PM at the east wing nursing station confirmed the facility failed to provide follow up ROM exercises in either of the RNP or the FMP.",2020-09-01
433,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,318,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for 1 resident (#28) of 3 residents reviewed for range of motion. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16, revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 Restorative Nurse Program (RNP) staff and 3 Functional Maintenance Program (FMP) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review revealed 0 days of splint or brace assistance. Medical record review of Occupational Therapy Plan dated 4/4/17, revealed Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #23 on 5/8/17 at 8:34 AM in her room revealed resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 8:43 AM at the west hall nurse's station reported Resident #28 is not in the RNP program. Interview with LPN #1 on 5/9/17 at 4:40 PM revealed this resident did not have foot drop at the time of admission. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director on 5/9/17 at 2:34 PM at the east wing nurse's station confirmed the facility failed to provide follow up ROM exercises by either the RNP or the FMP.",2020-09-01
435,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,623,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer or discharge for 2 of 3 (Resident #20 and 49) sampled residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Late Entry For 03/23/2018 .Pt (patient) was ordered to be sent to ER (emergency room ) for eval (evaluation) due to hx (history) of bowel obstruction . Review of the medical record revealed Resident #20 was admitted to the hospital 3/23/18. Interview with the Social Worker on 5/8/18 at 2:50 PM, in the Social Worker's office, the Social Worker was asked if the Ombudsman had been notified of Resident #20's transfer to the hospital. The Social Worker stated, .( I ) started (MONTH) 30th I thought the last Social Worker had notified the Ombudsman . The Social Worker was unable to locate the notification. 2. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Send patient to ER by EMS (Emergency Medical Service) STAT (now) . Review of the medical record revealed Resident #49 was admitted to the hospital 2/6/18. Interview with the Social Worker on 5/9/18 at 5:00 PM, in the Social Worker's office, the Social Worker was asked if the Ombudsman had been notified of Resident #49's transfer to hospital. The Social Worker was unable to provide documentation the Ombudsman was notified of the transfer.",2020-09-01
436,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,690,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide appropriate care and services for a [MEDICATION NAME] to prevent the potential for urinary tract infections for 1 of 1 (Resident #5) sampled residents reviewed with a [MEDICATION NAME]. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 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, required staff assistance with all activities of daily living (ADLs), had an ostomy, and had a [MEDICAL CONDITION] (MDRO). The care plan dated 11/27/17 documented, .Self-Care deficit .requires assistance for ADL function and mobility .has a [DIAGNOSES REDACTED].has a [MEDICATION NAME] and [MEDICAL CONDITION] .requires extensive assistance .to assist with changing .devices .is receiving IV (intravenous) meds (medications) .R/T (related to) .ESBL in urine .Date Initiated .5/07/2018 .on isolation R/T: ESBL in .urine . The physician's orders [REDACTED].Change bsb (bedside bag) to [MEDICATION NAME] q (every) 2 weeks .Start Date .3/22/2018 .Change .[MEDICATION NAME] appliances qod (every other day) .Start Date .2/08/2018 . Review of the Treatment Administration Records (TAR) revealed no documentation the [MEDICATION NAME] bedside bag was changed as ordered on [DATE], or that the [MEDICATION NAME] appliance was changed as ordered on [DATE], 3/12/18, 3/16/18, 3/20/18, 3/22/18, 3/24/18, 3/26/18, 4/1/18, 4/3/18, 4/5/18, 4/7/18, 4/9/18, 4/11/18, 4/15/18, 4/17/18, 4/21/18, 4/23/18, 4/25/18, 4/27/18, or 5/1/18. A hospital history and physical dated 5/4/18 documented, .past medical history significant for .chronic urinary tract infections .[MEDICATION NAME] .ASSESSMENT .Urinary tract infection .has a very strong history of extended-spectrum beta-lactamases . The final discharge orders dated 5/7/18 documented, .Cont (Continue) [MEDICATION NAME] .care . Observations in Resident #5's room on 5/8/18 at 7:50 AM, revealed Resident #5 lying in bed on a bolster-type mattress. The [MEDICATION NAME] drainage tubing was resting on the side of the bolster mattress in an inclined position. Resident #5 complained the mattress was causing difficulty with the urine drainage. Observations in Resident #5's room on 5/9/18 at 2:51 PM, revealed Resident #5 lying in the bed on a low air loss bolster mattress. Licensed Practical Nurse (LPN) #1 was at bedside to change the [MEDICATION NAME] appliance bag. The [MEDICATION NAME] bag to the right side of the abdomen was full of yellow urine. LPN #1 attempted to drain the urine from the [MEDICATION NAME] bag into the drainage tubing, but drainage was impaired by the incline of the side of the bolster mattress. After several attempts to drain the urine by manipulating the tubing, LPN #1 finally pressed down the side of the bolster mattress, which changed the position of the drainage flow downward, and immediately drained 300 milliliters of yellow urine into the drainage bag. Interview with the Director of Nursing (DON) on 5/9/18 at 4:27 PM, in the conference room, the DON was asked if it was appropriate for the [MEDICATION NAME] drainage tubing to be resting on an incline, preventing it from draining. The DON confirmed it was not, and stated, .Positioning is important with her . Observations in Resident #5's room on 5/9/18 at 7:45 AM, revealed Resident #5 lying in bed, covered with bed linens. The [MEDICATION NAME] tubing was connected to the drainage bag, and the drainage bag was lying on the floor. Interview with the DON on 5/9/18 at 4:27 PM, in the conference room, the DON was asked if it was appropriate for the drainage bag to be on the floor. The DON stated, No. Interview with the DON on 5/9/18 at 4:48 PM, in the conference room, the DON was asked about the missing documentation for changing the [MEDICATION NAME] appliance and bedside bag on the TARs. The DON stated, .They failed to document . The DON was asked if that was acceptable. The DON stated, They should be charting it .",2020-09-01
437,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,880,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to prevent the potential spread of infections when 1 of 1 (Assistant Director of Nursing (ADON)) staff member failed to perform appropriate hand hygiene during wound care. The findings included: The facility's Handwashing/Hand Hygiene policy documented, .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Employees must wash their hands .Before and after direct resident contact .Before and after performing any invasive procedure .Before and after changing a dressing .After contact with a residents mucous membranes and body fluids .After handling soiled or used linens, dressing . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of wound care in Resident #45's room on 5/8/18 at 4:21 PM, revealed the ADON gathered supplies, entered Resident 45's room, and donned gloves without performing hand hygiene. The ADON cleaned an open wound to Resident #45's right foot with sterile saline and gauze, and then applied Santyl to the wound using gauze with the same gloved hands. The ADON did not change gloves or wash hands between the dirty and clean procedure. The ADON moved to the surgical incision to the right ankle, and swabbed it with a [MEDICATION NAME] swabstick. Next, the ADON moved to a large dark purplish-black discolored wound to the right heel and sprayed it with skin prep, and then applied clean foam dressings to the wounds with the same gloved hands. The ADON did not perform hand hygiene between the ankle wound and the heel wound, and did not perform hand hygiene between cleaning the wounds and applying clean dressings. Interview with the ADON on 5/8/18 at 4:38 PM, outside of Resident #45's room, the ADON was asked if she should have washed her hands before providing wound care. The ADON stated, Yes, I didn't did I . The ADON was asked if she should have washed her hands between glove changes. The ADON stated,Yes. The ADON confirmed she should have performed hand hygiene between each wound. Interview with the Director of Nursing (DON) on 5/9/18 at 4:27 PM, in the conference room, the DON was asked when she expected staff to wash hands. The DON stated, Every time they are ready to do something with a resident . The DON was asked if she expected them to wash hands between glove changes. The DON stated, Yes. The DON was asked if she expected staff to perform hand hygiene between wounds during wound care. The DON stated, Yes.",2020-09-01
438,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-11-27,725,D,1,0,Y85H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility staffing schedules, review of the time detail reports, observation, and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 of 27 (11/3/19, 11/11/19, 11/13/19, 11/15/19, 11/23/19, and 11/24/19) days in Novenber. The facility had a census of 55 residents. The findings include: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a BIMS score of 14, which indicated no cognitive impairment. Interview with Resident #1 on 11/26/19 at 12:50 PM, in Resident #1's room, Resident #1 was asked if there was enough staff at the facility to give her the care she needed. Resident #1 stated, I'm blind so I have a hard time getting to the bathroom at night .I believe they need more help. Observation on 11/26/19 at 11:25 AM and 12:50 PM in Resident #1's room, revealed Resident #1 with hair that appeared oily and there was a urine odor in her room. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #2 on 11/26/19 at 5:20 PM, in Resident #2's room, Resident #2 was asked if there was enough staff to give her the care she needed. Resident #2 stated, There is not enough staff here and they don't answer the call lights timely on days or nights . 3. Observations on 11/26/19 at 12:03 PM at the East Nurses Station, revealed a family member of Resident #4 complaining to the staff member at the desk that his sheets were dirty and the room smelled of urine. Observations of Resident #4's room revealed the sheets had yellowish stains visible and the room did have an odor of urine. Interview with Resident #4 and 2 of his family members on 11/26/19 at 12:09 PM, in Resident #4's room, the family member stated, .came to take (Resident #4) out for Thanksgiving dinner and he (Resident #4) was upset because his sheets are dirty and the room smells of urine. 4. Review of the Certified Nursing Aide (CNA) schedule for 11/3/19 revealed that CNA #7 and #8 were scheduled for the night shift (11:00 PM - 7:00 AM) on 11/3/19. The actual time detail revealed only 1 CNA (CNA #8) worked on the night shift. The facility had a census of 59 residents. Review of the CNA schedule for 11/11/19 revealed that CNA #5, #12, and #13 were scheduled for 3:00 PM - 11:00 PM shift. Review of the actual time detail revealed 2 CNAs (CNA #5 and #12) worked the 3:00 PM - 11:00 PM shift on 11/11/19. The facility had a census of 53 residents. Review of the actual time detail revealed one CNA (CNA #12) worked on 11/13/19 on the 3:00 PM - 11:00 PM shift. The facility had a census of 52. Review of the CNA schedule for 11/15/19 revealed that CNA #10 and #11 were scheduled for 11:00 PM - 7:00 AM. Review of the actual time detail revealed only 1 CNA (CNA #11) worked on 11/15/19 for the 11:00 PM - 7:00 AM shift. The facility had a census of 52. Review of the CNA schedule for 11/23/19 revealed that CNA #9, #10, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/23/19. The facility had a census of 56. Review of the CNA schedule for 11/24/19 revealed CNA # 8, #9, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/24/19. The facility had a census of 55. 5. Interview with CNA #1 on 11/26/19 at 1:12 PM, in the Conference Room, CNA #1 was asked if there was enough staff for the residents to receive the care they needed. CNA #1 stated, .no not always enough time to complete everything .not enough staff for all the residents to get showers, just bed baths. They don't get the care they need. CNA #1 was asked how many residents she was assigned today. CNA #1 stated, today 12 .responsible for 18 sometimes .Laundry is only here 8 hours and we often run out of sheets, washcloths, and towels. The first weekend of November, I worked 25 hour shift due to no one showing up for third shift . Interview with CNA #2 on 11/26/19 at 1:42 PM, in the Conference Room, CNA #2 was asked if there was enough staff for the residents to receive the care they needed. CNA #2 stated, No need more CNAs . CNA #2 was asked how many residents she was assigned today. CNA #2 stated, .I have 13 .I stay over until 7:00 PM, if they have a call in. We do run out of clean sheets and washcloths due to laundry only doing one shift . Interview with CNA #3 on 11/26/19 at 2:05 PM, in the Conference Room, CNA #3 was asked if there was enough staff for the residents to receive the care they needed. CNA #3 stated, No, no residents on 700 hall had showers today, they got bed baths. CNA #3 was asked how many residents she was assigned today. CNA #3 stated, Today 12 .I have worked West (hall) by myself with 22 residents Interview with CNA #4 on 11/26/19 at 2:27 PM, in the Conference Room, CNA #4 was asked if there was enough staff for the residents to receive the care they needed. CNA #4 stated, Not enough staff to give care needed .last week 3 days I was by myself on second shift on West (hall) with 22 residents . CNA #4 was asked how many residents she was assigned today. CNA #4 stated, 12 today. Interview with CNA #5 on 11/26/19 at 2:53 PM, in the Conference Room, CNA #5 was asked if there was enough staff for the residents to receive the care they needed. CNA #5 stated, Absolutely short staffed to give the care these residents need .I have stayed over when only one CNA on third shift . Interview with the Administrator on 11/26/19 at 3:40 PM, in the Conference Room, the Administrator was asked about the working schedule. The Administrator stated, I had to take over the scheduling in mid-November. The person that had been doing the schedule had been doing it since (MONTH) and had been doing really good. But then she was making a hot mess of it, she didn't have them accurate. She was leaving people off the assignments sheets and schedule . Interview with Licensed Practical Nurse (LPN) #1 on 11/26/19 at 3:50 PM, in the Conference Room, LPN #1 was asked if there was enough staff for the residents to receive the care they needed. LPN #1 stated, No I don't. LPN #1 was asked if the residents appeared clean when she arrived or if she noticed any odors. LPN #1 stated, .I have noted oily hair on residents and odors occasionally. Interview with CNA #6 on 11/26/19 at 5:04 PM, on the 300 Hall, CNA #6 was asked if there was enough staff for the residents to receive the care they needed. CNA #6 stated, .I was on East (hall) with 30 residents by myself .worked 2 nights by myself. Interview with CNA #7 on 11/27/19 at 6:00 AM, in the Conference Room, CNA #7 was asked if there was enough staff for the residents to receive the care they needed. CNA #7 stated, No there is not enough staff .we run out of linens regularly most nights lately . CNA #7 was asked how many residents she was assigned. CNA #7 stated, 22. Interview with CNA #8 on 11/27/19 at 6:20 AM, at the East Nurses Station, CNA #8 was asked if there was enough staff for the residents to receive the care they needed. CNA #8 stated, No not enough for the residents to get care needed .often one CNA for the whole building .",2020-09-01
439,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,638,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 2 of 19 (Resident #2 and #5) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 7/3/19 revealed Item Z0500B was not completed. The MDS should have been completed by 7/17/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 7/3/19 MDS for Resident #2 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If it is from July, then yes. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 8/2/19 revealed Item Z0500B was not completed. The MDS should have been completed by 8/16/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 8/2/19 MDS for Resident #5 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If that was the ARD date, then, yes it should have.",2020-09-01
440,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,759,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH Edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 29 opportunities, resulting in an error rate of 10XXX 759% The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin . [MEDICATION NAME] . Rapid-Acting Insulin .ONSET .15 min . ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].= 5 (units) .300-349 = 10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered to Resident #18 until a meal tray was delivered at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #1. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered to Resident #18 until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #2. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered to Resident #24 until a meal tray was delivered at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in medication administration error #3. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.",2020-09-01
441,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,760,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications free of significant medication errors. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin .[MEDICATION NAME] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].=5 (units) .300-349 =10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered until a meal tray was delivered to Resident #18 at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. 3. Medical record review revealed Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered until a meal tray was delivered to Resident #24 at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in a significant medication error. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.",2020-09-01
442,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,880,D,0,1,7V2811,"**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 practices to prevent the potential spread of infection were maintained for 1 of 2 (Resident #48) sampled residents observed during a dressing change. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th EDITION documented, .Keep the drainage bag in a dependent position, below the level of the bladder . 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. A physician's orders [REDACTED].Cleanse wound to sacral area with Dakins, pat dry, Apply Calcium Alginate and Collogen dressing to wound bed, cover with ABD (abdominal) pad, secure with border dressing daily every day shift . A physician's orders [REDACTED].May change indwelling silicone silver tip catheter number 18 Fr (french) 30 cc (cubic centimeters) bulb as needed for [MEDICAL CONDITION] . 4. Observations in Resident #48's room on 9/24/19 at 2:20 PM, revealed Registered Nurse (RN) #1 performed dressing changes with the assistance of Certified Nursing Assistant (CNA) #1 and CNA #2. CNA #1 placed Resident #48's indwelling urinary catheter tubing and bag on the foot of the bed during the dressing change. CNA #1 and #2 changed a blue pad saturated with bloody drainage from the resident's sacral wound by rolling the resident, and placed a clean, dry blue pad under the resident on top of a bed sheet that was saturated with wound drainage. After the dressing change, Resident #48 was positioned in the bed and the bedside drainage bag was positioned back under the bed at 3:03 PM, 35 minutes later. Interview with CNA #1 on 9/24/19 at 3:05 PM, in Resident #48's room, CNA #1 was asked if it was appropriate to leave the catheter bag on the bed during the dressing change. CNA #1 stated, no . Interview with CNA #2 on 9/24/19 at 3:07 PM, in Resident #48's room, CNA #2 was asked if it was appropriate to cover the saturated bed linen with a clean blue pad. CNA #2 stated, .no .we did not have the supplies in the room . Interview with the Director of Nursing (DON) on 9/25/19 at 11:25 AM, in the DON Office, the DON was asked if it was appropriate to place a bedside drainage bag in the bed with a resident during a dressing change. The DON stated, .no ma'am . The DON was asked it was appropriate to replace blue pads over bed linen that was saturated with drainage from a wound. The DON stated, .all of the linens should have been changed .",2020-09-01
443,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-08-03,686,D,1,0,Q36011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to notify the physician of a new area of skin breakdown for 1 of 3 sampled residents (Resident #11) reviewed for pressure ulcer/injury to the skin. The findings include: The facility's Pressure Ulcer/Injury Risk Assessment policy revised (MONTH) (YEAR) documented, .Notify attending MD (medical doctor) if new skin alteration noted . The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revised (MONTH) 2014 documented, .The physician will authorize pertinent orders related to wound treatments .and application of topical agents if indicated for type of skin alteration . The facility's Pressure Ulcers/Injuries Overview policy revised (MONTH) (YEAR) documented, .Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was sometimes understood with a cognitive score of 3 of 15 indicating severe cognitive impairment and the presence of disorganized thinking; required extensive assistance of 2 staff for bed mobility; was dependent for toileting;and was always incontinent of bowel and bladder. Review of the comprehensive plan of care initiated following the admission MDS assessment dated [DATE] and updated 7/24/18 revealed appropriate care plan interventions were implemented for assessed problems and needs which included risk for skin impairment related to incontinence, immobility, combativeness, resistance and refusal of care during personal care. Review of the C.N.[NAME] (Certified Nursing Assistant (CNA)) SKIN CARE ALERT dated 7/19/18 revealed a new red area was identified on Resident #11's right upper buttocks during bathing. Following the CNA notifying Licensed Practical Nurse (LPN) #2, the LPN documented her assessment findings in a SKIN OBSERVATION TOOL - (Licensed Nurse) dated 7/19/18. Review of her skin assessment revealed the resident's right and left buttocks had excoriated areas and documented, .two small areas of open areas smaller than a penny . There was no documentation in the nursing progress notes or physician telephone orders of the physician being notified of the change in the condition of the resident's skin or receipt of any orders for treatment of [REDACTED]. Review of a nursing progress note dated 7/23/18 revealed LPN #1, the wound care nurse, was notified of Resident #11's change in skin condition, assessed the skin, notified the Wound Physician and received new treatment orders. The Wound Physician would follow up to evaluate the resident's wound on 7/25/18. Review of a physican order dated 7/23/18 revealed orders for daily and as needed wound cleansing, treatment and dressing change. Review of a wound assessment follow up note by LPN #1 dated 7/29/18 revealed the resident's buttocks wounds and surrounding area of skin appeared to be caused by shearing and additional appropriate care plan interventions were put into place. Interview with the 4th floor Unit Manager (UM) and LPN #1 on 7/23/18 at 3:25 PM in the 4th floor UM office, the UM was asked about Resident #11's skin breakdown identified by the CNA on 7/19/18. The UM revealed, LPN #1 and the Wound Physician had evaluated Resident #11's skin on 7/18/18 and he had no wounds present at that time. The UM and LPN #1 were not notified of the resident's skin breakdown until 7/23/18. The UM revealed, according to her review of documentation and interview with staff on duty on 7/19/18, the CNA had documented and notified the nurse on duty of the appearance of Resident #11's skin and nursing documentation revealed open areas on his buttocks. The UM stated, .The nurse didn't reach out or document . LPN #1 was asked if Resident #11 was turned and repositioned. LPN #1 revealed the resident resisted turning and repositioning and braced his hands on the upper side rails, pushing against staff who were trying to reposition him. Interview with LPN #1 on 7/26/18 at 12:25 PM in the Chapel, when asked about Resident #11's change in skin condition identified on 7/19/18, LPN #1 confirmed the resident's prior buttock wound had healed on 6/13/18, and on 7/19/18 new areas on his buttocks were identified. LPN #1 stated the preventive barrier cream in use prior to the new skin breakdown was not an appropriate treatment for [REDACTED].#2 should have notified her or the physician of the change in condition. LPN #1 stated when she was made aware of Resident #11's skin condition on 7/23/18, she had assessed the resident's skin and contacted the Wound Physician for appropriate treatment orders. Interview with the Director of Nursing (DON) on 8/1/18 at 12:15 PM in the DON's office, when asked about the facility's protocol for notification of changes in residents' skin, the DON stated, .for open areas, the nurse should notify her (LPN #1) immediately or the physician .",2020-09-01
444,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2019-09-17,641,D,0,1,VPVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure assessments were completed accurately to reflect the resident's status for transfers and Range of Motion (ROM) for 2 of 31 (Resident #37 and 80) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #37 required limited assistance with transfers during the 7 day look back period. Review of the Documentation Survey Report dated (MONTH) 2019, revealed Resident #37 received extensive assistance with transfers on 4/4/19, 4/5/19, 4/7/19, 4/8/19, and 4/10/19. Interview with MDS Coordinator #1 on 9/17/19 at 3:00 PM, in the Chapel, MDS Coordinator #1 was asked if the quarterly assessment dated [DATE] was coded accurately to reflect the residents ability to transfer. MDS Coordinator #1 stated, No, that's not the way I would have coded it . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed Resident #80 had no impairment to the upper extremities or lower extremities. The annual MDS was not coded to reflect Resident #80's left sided ROM impairments. The comprehensive care plan revised 8/7/19 documented, .ADL (Activities of Daily Living) self-care performance deficit r/t (related/to) [MEDICAL CONDITION] .Limited Mobility, Stroke .Contractures of the L (left) arm .L side Paralysis . Observations in Resident #80's room on 9/15/19 at 3:14 PM and 9/16/19 at 1:37 PM, revealed Resident #80's mouth drooped on the left side and her left hand appeared to be contracted. Resident #80 was unable to straighten her arm or hand. Interview with MDS Coordinator #1 on 9/17/19 at 3:16 PM, in the Chapel, MDS Coordinator #1 was asked if the annual MDS dated [DATE] was coded correctly for range of motion limitation. MDS Coordinator #1 stated, No. MDS Coordinator #1 was asked how it should have been coded. MDS Coordinator #1 stated, Limitation on 1 side, the left side. Interview with the Occupational Therapist (OT) on 9/17/19 at 5:11 PM, in the Chapel, the OT confirmed Resident #80 had left-sided range of motion impairment.",2020-09-01
445,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2019-09-17,761,D,0,1,VPVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and securely when 1 of 11 (Respiratory Medication Cart) medication storage areas was left unlocked and unattended and 1 of 8 (Respiratory Therapist (RT) #1) staff members left medications out of sight and unattended. The findings include: 1. The facility's Storage of Medications policy with a revision date of (MONTH) 2007, documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 2. Observations in the 3rd Floor West Hall in front of room [ROOM NUMBER] on 9/17/19 at 8:50 AM, revealed the Respiratory Medication Cart was unlocked and unattended. Observations during medication administration in Resident #84's room on 9/17/19 at 8:55 AM and 9:02 AM, revealed RT #1 entered Resident #84's room to administer an inhalation medication. RT #1 placed an inhaler on the over bed table, and entered the bathroom to wash his hands, leaving the medication out of sight and unattended. RT #1 returned to bedside to administer the inhaler, but then left the room to get an alcohol pad, leaving the medication out of sight and unattended. 3. Interview with the Director of Nursing (DON) on 9/17/19 at 2:24 PM, in the DON office, the DON was asked if the medication cart should be left unlocked and unattended, and if medications should be left at the bedside unattended. The DON stated, No.",2020-09-01
447,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,623,D,0,1,W4ME11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 2 of 5 (Resident #68 and 147) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #68 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Progress Notes dated 9/15/18 documented, .resident transferred to (Named Hospital) for Mental Status Change, doctor and family notified .resident returned at 6:45 PM from (Named Hospital) . Review of the Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #68's name was not on this list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #68 had been transferred to the hospital. Interview with the Director of Nursing (DON) on 11/14/18 at 5:45 PM in the Chapel, the DON confirmed this resident was not on the list and stated, I didn't think we notified if they leave and come right back . 3. Medical record review revealed Resident #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Progress Notes dated 7/28/18 documented, .CNA (Certified Nursing Assistant) alerted the writer that resident was non-responsive .T.O. (telephone order) given to send resident to ER .5:55 AM Transportation arrived to transport resident . Review of the Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #147's name was not on this list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #147 had been transferred to the hospital. Interview with the Social Services Director on 11/15/18 at 2:26 PM in the Chapel, the Social Services Director was asked if the Ombudsman was notified when residents are discharged or transferred from the facility. The Social Services Director stated, Yes, ma'am. The Social Services Director was then asked how it was determined which residents to put on the log for notification of transfer or discharge. The Social Services Director stated, The way I was told is that if they do not stay past midnight then we do not count them and if they weren't long term care then I didn't count them . The Social Services Director was asked if a resident goes to the hospital and doesn't stay past midnight are they placed on the log and if they are not long term care residents they are not put on the log. The Social Services Director stated, Yes, ma'am . The Social Services Director was then asked if Resident #147 should have been on the (MONTH) (YEAR) log. The Social Services Director stated, .he was short term so no he was not on the list .",2020-09-01
449,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,812,D,0,1,W4ME11,"Based on policy review, observation, and interview, 2 of 23 (Certified Nursing Assistant (CNA) #2 and 1) staff members failed to serve food under sanitary conditions during dining observations and the facility failed to ensure enteral feedings were stored under sanitary conditions as evidenced by 9 enteral feedings were stored past the use by date in 1 of 3 (3rd Floor) nourishment rooms. The findings include: 1. The facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated (MONTH) 2008 documented, .1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness .6. Employees must wash their hands: .h. After engaging in other activities that contaminate the hands . 2. Observations in the West 400 hall on 11/13/18 beginning at 12:03 PM revealed CNA #2 entered Resident #96's room and delivered a meal tray to the resident. CNA #2 assisted the resident up in the bed with the assistance of another CNA, and CNA #2 continued to set up the resident's meal tray without performing hand hygiene. CNA #2 then entered Resident #116's room and delivered a meal tray to the resident without performing hand hygiene, set up the meal tray, adding salt and pepper to the food, and sugar to the tea. CNA #2 then delivered a meal tray to Resident #110's room and set up the meal tray without performing hand hygiene. Observations in the North 400 hall on 11/13/18 beginning at 12:27 PM revealed CNA #1 entered Resident #103's room, delivered and set up a meal tray to the resident without performing hand hygiene. CNA #1 then entered Resident #79's room, delivered and set up the meal tray without performing hand hygiene. Observations in the 400 Hall dining room on 11/15/18 at 8:11 AM revealed CNA #1 warmed Resident #91's meal tray and then began to feed the resident. As CNA #1 was feeding the resident, CNA #1 blew on the food, prior to giving the resident a bite to cool the food. This was done 5 times as he fed the eggs to the resident. Interview with the Director of Nursing (DON) on 11/15/18 at 10:47 AM in the Chapel, the DON was asked what should staff do after assisting residents, touching things in the rooms, and prior to setting up meal trays or delivering meal trays. The DON stated, Should use hand gel or wash hands. The DON was asked if staff should blow on food to cool it prior to giving the food to a resident. The DON stated, No. 3. Observations in the 3rd Floor nourishment room on 11/14/18 at 8:45 AM, revealed 9 bottles of Glucerna 1.2 (an enteral feeding) with a use by date of (MONTH) (YEAR). Interview with Licensed Practical Nurse #1 (LPN) on 11/14/18 at 8:47 AM, in the 3rd Floor nourishment room, LPN #1 was asked should these 9 bottles of enteral feedings past the use by date be stored here. LPN #1 stated, .No, it shouldn't . Interview with the DON on 11/15/18 at 9:16 AM, in the chapel, the DON was asked should any enteral feedings with a use by date of (MONTH) (YEAR) be stored in the nourishment room. The DON stated, No, it should not .",2020-09-01
450,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,637,D,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.15 (MONTH) 1, (YEAR), medical record review, and interview, the facility failed to ensure a significant change in status assessment was completed related to hospice services on 1 of 33 (Resident #34) sampled residents reviewed. The findings included: The MDS 3.0 RAI Manual v 1.15 (MONTH) 1, (YEAR) page 46 documented, .A SCSA (Significant Change in Status Assessment) is required to be performed when a terminally ill resident enrolls in a hospice program Medical record review revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/27/17 documented, .HOSPICE/Terminal illness .Resident is diagnosed with [REDACTED]. The physician's orders [REDACTED].>No significant change MDS assessment was completed when Resident #34 was admitted to hospice services. Interview with MDS Coordinator #1 on 12/7/17 at 8:18 AM, in the MDS office, MDS Coordinator #1 was asked if a significant change assessment should have been completed when Resident #34 was admitted to Hospice. MDS Coordinator #1 stated, Yes .",2020-09-01
452,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,641,D,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for falls and [MEDICAL CONDITION] care for 2 of 33 (Resident #55 and 62) sampled residents reviewed. The findings included: 1. Medical record review revealed resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Assessment for Resident #55 revealed falls with no injury on 7/9/17, 8/31/17, and 9/4/17. The quarterly Minimal Data Set ((MDS) dated [DATE] documented no falls since the last MDS assessment. Interview with MDS Coordinator #1 on 12/7/17 at 8:20 AM, in the MDS office, MDS Coordinator #1 was asked if the 9/6/17 MDS should have been coded to reflect falls. MDS Coordinator #1 stated, Yes, 2 or more . 2. Medical record review revealed Resident #62 was admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. Review of the quarterly MDS dated [DATE] revealed [MEDICAL CONDITION] care was not marked as being performed. Interview with MDS Coordinator #1 on 12/7/17 at 8:20 AM, in the MDS office, MDS Coordinator #1 was asked if the 9/8/17 MDS should have been coded to reflect [MEDICAL CONDITION] care. MDS Coordinator #1 stated, Yes.",2020-09-01
453,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,689,D,0,1,IIYT11,"**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 intervention measures were in place for 1 of 3 (Resident #55) sampled residents reviewed for falls. The findings included: 1. The facility's Falls policy documented, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injury. 2. Medical record review revealed resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/18/17 revealed .risk for fall .7/9/17 mats at bedside . Review of the (Named Facility) Nursing Assessment for (Resident #55) revealed falls with no injury on 7/9/17, 8/31/17, 9/4/17, 9/26/17, 10/13/17, and 11/23/17. The Certified Nursing Assistant (CNA) care guide (not dated) documented, RESIDENT CARDEX INFO (Information) .OVERALL EVALUATION .LOW BED WITH MATS . The Nursing Assessment for Resident #55 dated 9/4/17 documented, .Fall specific information .RESIDENT SLID OUT OF BED LYING ON HER RIGHT SIDE NEXT TO AIR CONDITION UNIT .Area of fall and position patient was found: LYING ON RT (right) SIDE . The Nursing Assessment for Resident #55 dated 9/26/17 documented, .Fall specific information .pt (patient) on the floor in a sitting position with back against the bed .Area of fall and position patient was found: .floor to pt's (patient's) right side of bed . The Nursing Assessment for Resident #55 dated 10/13/17 documented, .Fall specific information .Resident noted to be on floor beside bed on mat .Area of fall and position patient was found: .Noted on left side of bed on mat, lying on right side . Observations in Resident #55's room on 12/5/17 at 7:59 AM, revealed Resident #55 lying in bed on her right side, eyes closed, without mats on the floor at bedside. Interview with Unit Manager #1 on 12/5/17 at 4:56 PM, at the 300 hall nurses station, Unit manager #1 was asked what fall interventions Resident #55 should have in place. Unit Manager #1 stated, Mats at bedside when in bed . Interview with Unit Manager #1 on 12/5/17 at 5:42 PM, in Resident #55's room, Unit Manager #1 confirmed no mats were in the room or bathroom to be placed at the bedside. Observations in Resident #55's room on 12/6/17 at 8:03 AM, revealed Resident #55 in bed with a mat on the floor on the Resident's left side of the bed, another mat was in the room, stored between the wall and the side of the closet. Interview with Unit Manager #1 on 12/6/17 at 8:31 AM, at the 300 hall way nurses station, Unit Manager #1 was asked which side of the bed the mats in Resident #55's room should be placed on. Unit Manager #1 stated, We put it on the side where she actually gets out of bed, where she fell . In Resident #55's room, Unit Manager #1 confirmed that Resident #55 should have a fall mat on the right side of the bed. Interview with the Director of Nursing (DON) on 12/7/17 at 10:01 AM, in the DON office, the DON was asked if she would expect to see Resident #55 in bed without fall mats in place. The DON stated, No, she should have them when she is in bed .",2020-09-01
454,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,761,D,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 9 (Licensed Practical Nurse (LPN) #1) nurses failed to ensure medications and biologicals were stored safely when medications were left unattended in a resident's room during medication administration. The findings included: 1. The facility's STORAGE OF MEDICATION policy documented, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication . Observations in Resident #28's room on 12/5/17 at 9:10 AM, revealed LPN #1 entered the room, placed a [MEDICATION NAME] injection on the resident's overbed table at the bedside. LPN #1 went into the resident's restroom before administering the medications, leaving the medications unattended and out of sight. Interview with the Director of Nursing (DON) on 12/5/17 at 9:36 AM, in the 200 hall dining room, the DON was asked if it was acceptable to leave medication in the resident's rooms unattended. The DON stated, No .it is not acceptable.",2020-09-01
455,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,550,D,0,1,EIX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Federal Resident / Patient Rights, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 15 (Certified Nurse Assistant (CNA) #2 and 3, and Dietary Cook #1) staff members failed to knock before entering a room. The findings included: 1. The Federal Resident/Patient Rights documented, Every facility resident has a right to a dignified existence . Observations on the west hall on 2/11/18 at 11:53 AM, revealed CNA #2 delivered meal trays to rooms 107, 110 and 115. CNA #2 failed to knock on the door or announce herself prior to entering the rooms. Observations on the west hall on 2/11/18 at 12:31 PM, revealed Dietary Cook #1 delivered a sandwich to room [ROOM NUMBER] and failed to knock on the door or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #2 delivered a meal tray to room [ROOM NUMBER], placed the tray on the over bed table and exited the room and then returned. CNA #2 failed to knock or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #3 delivered meal trays to room [ROOM NUMBER] and 117. CNA #3 failed to knock or announce herself prior to entering the rooms. Interview with the Director of Nursing (DON) on 2/13/18 at 2:57 PM, in the human resource conference room, the DON was asked what should staff to do before entering a room. The DON stated, I expect them to knock and announce themselves . The DON was then asked what should staff to do when their arms are full. The DON stated, If they have their hands full I still expect them to announce themselves.",2020-09-01
456,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,693,D,0,1,EIX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for a tube feeding for 1 of 2 (Resident #230) sampled residents reviewed with a tube feeding. The findings included: Medical record review revealed Resident #230 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/29/18 revealed Resident #230 was at nutrition and/or hydration risk with approaches to provide Percutaneous Endoscopic Gastrostomy (PEG) feeding as ordered. The physician's orders dated 2/2/18 documented, .[MEDICATION NAME] 1.5 cal (calorie) per peg tube at 50 cc (cubic centimeters)/hr (hour) for 22 hours, on at 8am, off at 6am . Observations in Resident #230's room on 2/11/18 at 2:44 PM and 4:57 PM, revealed Resident #230 was in the bed, [MEDICATION NAME] 1.5 was infusing at 55 ml/hr. Interview with Registered Nurse (RN) #1 on 2/12/18 at 2:20 PM, at the 200 hall medication cart, RN #1 was asked what Resident #230's feeding rate should be. RN #1 stated, 55 .oh no .50 . RN #1 confirmed Resident #230's feeding rate was infusing at 55 cc/hr. Interview with the Director of Nursing (DON) on 2/13/18 at 10:26 AM, in the Admissions office, the DON was asked if she expected her staff to follow the physician's orders. The DON stated, Yes. The DON was asked if an order for [REDACTED].",2020-09-01
457,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,695,D,0,1,EIX211,"**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 appropriate oxygen therapy for 1 of 6 (Resident #74) sampled residents reviewed for oxygen therapy. The findings included: The facility's Departmental (Respiratory Therapy) - Prevention of Infection policy documented, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannulae (cannula) and tubing every seven (7) days, or as needed . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. O2 (oxygen) @ (at) 2L (liters) BNC (binasal cannula) . The care plan dated 2/7/18 documented, .Problem .Resident has [MEDICAL CONDITION] condition/Dx (diagnosis) of [MEDICAL CONDITIONS] exacerbation, resp (respiratory)failure .Approach .Change O2 tubing once a week . Observations in Resident #74's room on 2/11/18 at 10:06 AM, 2:57 PM, 5:00 PM, and on 2/12/18 at 7:41 AM, and 2:03 PM revealed the oxygen tubing was dated, but the date was illegible, and the filter on the concentrator was dirty. Interview with Registered Nurse (RN) #1 on 2/13/18 at 10:20 AM, in Resident #74's room, she was asked when this O2 tubing was changed. RN #1 confirmed the date could not be read and stated, I will change it, can not tell when was changed. RN #1 confirmed the filter was dirty and stated, will need to change. RN #1 was asked if they document when the tubing or the filter would be changed. RN #1 stated, No, just date the tubing. Interview with the Director of Nursing (DON) on 2/13/18 at 10:33 AM, in the Admission office, the DON was asked how often O2 tubing and the filter should be changed. The DON stated, every week",2020-09-01
460,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,658,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, job description review, medical record review, and interview, the facility failed to ensure that licensed nurses did not borrow medications prescribed to one resident and administer those medications to another resident for 1 of 3 (Resident #1) sampled residents reviewed for medication administration. The findings included: 1. The facility's Medication Administration . policy documented, .Medications supplied for one resident are never administered to another resident . 2. The JOB DESCRIPTION .Charge Nurse (LPN or RN) (Licensed Practical Nurse or Registered Nurse) documented, .Essential Duties & Responsibilities .Prepare and administer medication as ordered by the physician .Verify that prescribed medication for one resident is not administered to another . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 31 hours before leaving against medical advice. The physician admission orders [REDACTED]. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed [MEDICATION NAME], and Duloxetine were delivered to the facility for Resident #1. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed [MEDICATION NAME] was delivered to the facility for Resident #1. The (MONTH) Medication Administration Record [REDACTED]. No [MEDICATION NAME] was delivered from the pharmacy due to no written prescription was available and sent to the pharmacy. Interview with the Director of Nursing (DON) on 5/9/18 beginning at 9:35 AM, in the conference room, the DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. The DON reviewed the MAR for the same resident and revealed documentation that 1 [MEDICATION NAME] was administered to that resident. Review of Resident #1's MAR indicated [REDACTED]. The DON was asked about Resident #1's MAR indicated [REDACTED]. The DON stated that even though other resident medications should not be borrowed, she confirmed the nurses did borrow medications from other residents and documented they were administered on Resident #1's MAR. The DON stated that the nurses should not borrow medications. The (MONTH) MAR indicated [REDACTED]. Telephone interview with LPN #1 on 5/9/18 at 10:00 AM, in the conference room, LPN #1 confirmed that she signed the [MEDICATION NAME] as given on the random resident's MAR indicated [REDACTED]. LPN #1 confirmed she administered the borrowed [MEDICATION NAME] it to Resident #1. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered [MEDICATION NAME] to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night and she confirmed that he did take the medication. LPN #1 confirmed that she did borrow medications from other residents.",2020-09-01
461,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,697,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, medical record review, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well-being for 1 of 3 (Resident #1) sampled residents reviewed for pain. The findings included: 1. The facility's Pain Management policy documented, .The purpose of this policy is to outline guidelines that will promote effective pain management, including .timely response to complaints of pain .Our facility is committed to help each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible. Our pain management policy includes recognizing when the resident experiences pain .and management or prevention of pain consistent with professional standards of care and in accordance with the plan of care .MANAGEMENT .When treating pain, start with drugs appropriate to the resident's current level of pain and progress by increasing the dose of that drug until maximum benefit is obtained . 2. The Residents Rights documented, .Nursing home residents have the right .to reside and receive services with reasonable accommodation .to voice grievances about care or treatment they do or do not receive .and to receive prompt response from the facility . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 32 hours. The Baseline Admission Care Plan documented, .Problem .Resident has pain .Related to .Diabetic [MEDICAL CONDITION] .Approach .Administer pain medications per physicians orders . The hospital physician admission orders [REDACTED]. The original handwritten prescriptions signed by the physician for these medications were not found when Resident #1 arrived to the facility via ambulance. Medical record review revealed Resident #1 did not receive [MEDICATION NAME] for pain, [MEDICATION NAME] for anxiety, or [MEDICATION NAME] for [MEDICAL CONDITION] during his stay at the facility. Review of the hospital medication reconciliation discharge paperwork dated 4/20/18 revealed Resident #1 had last received [MEDICATION NAME] on 4/15/18 at 3:14 AM, [MEDICATION NAME] on 4/19/18 at 9:50 PM, [MEDICATION NAME] on 4/20/18 at 11:22 AM, and [MEDICATION NAME] on 1/16/18 at 12:00 AM, while a patient in the hospital. The nurse's notes dated 4/21/18 at 2:57 AM, Licensed Practical Nurse (LPN) #1 documented, .CONCERNED WITH MEDS (Medications) NOT BEING HERE .RESIDENT NOT PLEASED .ASKING TO GO BACK TO HOSPITAL .NOW AT DESK REQUESTING PAIN PILL. MEDS STILL NOT AVAILABLE FROM PHARMACY .4:12 AM .AT DESK AT THIS TIME TALKING AGGRESSIVELY TO NURSE ABOUT HIS MEDS. WILL NOT ALLOW NURSE TO EXPLAIN MED SITUATION TO HIM. KEEPS OVERTALKING NURSE AND YELLING ABOUT THIS IS NOT RIGHT. REQUESTING THAT I CALL AMBULANCE FOR HIM TO GO BACK TO HOSPITAL. ADVISED THAT HE (Resident #1) MAY DO SO BUT IT WOULD NOT BE AN EMERGENCY TRANSFER FROM FACILITY .(RESIDENT #1) STATING .NURSE TOLD HIM THAT MEDS WERE ON THE WAY .I CANNOT GIVE HIM MEDS THAT I DO NOT HAVE . The (MONTH) MAR indicated [REDACTED]. Resident #1 was not administered any [MEDICATION NAME] from 4/20/18 at 11:22 AM (at the hospital) until 4/21/18 at 4:33 AM (at the nursing home facility). Resident #1 did not have any pain medication for a total of 17 hours and 11 minutes. Resident #1 did not receive any additional pain medication for an additional 21 hours and 17 minutes during his stay at this facility and he left against medical advice on 4/22/18 at 1:50 AM. On 4/21/18 at 5:43 AM, LPN #2 documented, .Writer then Called NP (Nurse Practitioner) on call .and explained the issue, she was given his dx (diagnosis) with chronic pain she ordered to give Tylenol 650mg every 4 hours as needed for pain. he refused to receive it saying it upsets his stomach. DON (Director of Nursing) then notified about issue. (Named Medical Director) was called but could not be reached at the time .DON was notified of unresolved issue, she ordered to transfer resident to hospital for uncontrolled pain .he refused and stated that [MEDICATION NAME] would be fine at the moment . The nurse's note dated 4/22/18 at 4:02 AM, documented, REPORTED PER VS (VITAL SIGNS) THAT BP (BLOOD PRESSURE) IS 176/99. PRN (AS NEEDED) [MEDICATION NAME] OFFERED WITH TYLENOL FOR C/O (COMPLAINT OF) PAIN. DECLINED TYLENOL. STATED IT CAUSES GI (GASTROINTESTINAL) UPSET. RESIDENT OBSERVED PACKING BELONGINGS AND STATED THAT HE WILL BE LEAVING TONIGHT .SAID HE WOULD CALL 911 OR AMBULANCE SERVICE. ADVISED TO ALLOW NURSE TO GIVEN HIM PRN FOR BP. STATED THAT HE COULD NOT TAKE IF HE DIDN'T HAVE HIS PAIN MED (MEDICATION) ALSO. INFORMED THAT NO PAIN MED AT THIS TIME EXCEPT TYLENOL AVAILABLE. (RESIDENT #1) REMAINED DETERMINED TO LEAVE. FINISHED PACKING ALL BELONGINGS AND AT DESK ASKING WHAT PAPER TO SIGN TO GET OUT OF HERE. PRESENTED WITH AMA (AGAINST MEDICAL ADVICE) PAPERS. READ OVER PAPERS AND SIGNED .OBSEVRED EXTING (OBSERVED EXITING) UNIT WITH PERSONAL BELONGS TOWARD FRONT DOOR OF FACILITY. ALARM SOUNDED OF EXIT AT 0150 AM .6:23 AM FACILITY ADMINISTRATOR AND DON MADE AWARE OF AMA OF RESIDENT. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed the following medications were delivered to the facility for Resident #1. [MEDICATION NAME] 30 tablets, Atorvastatin 30 tablets, [MEDICATION NAME] 30 tablets and Duloxetine 60 tablets. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed the following medications were delivered to the facility for Resident #1. Losartan 60 tablets, [MEDICATION NAME] 30 tablets, [MEDICATION NAME] 30 tablets and [MEDICATION NAME] 7 tablets. The DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. Review of Resident #1's (MONTH) MAR indicated [REDACTED]. Interview with Resident #1 on 5/8/18 beginning at 2:14 PM, in the conference room, he was asked about his stay at this facility in April. Resident #1 confirmed he was admitted to the facility at approximately 5:50 PM on 4/20/18 and the hospital sent written prescriptions with him in an envelope. He stated they lost the prescriptions and he did not get any pain medicine when he was there. He stated that he had [MEDICAL CONDITION] pain and anxiety. Interview with the DON on 5/9/18 beginning at 9:35 AM, in the conference room, she was asked about the facility's process if narcotic prescriptions are lost when residents are admitted to the facility. The DON stated that they cannot get narcotics if there is no written prescription. The DON stated that the facility was looking into the incident and would be doing a process improvement plan. The DON confirmed that Resident #1 should not have gone so long without pain medication. The DON was asked about Resident #1's continued requests for medication. The DON confirmed that Resident #1 was hard to manage and he was not truthful. She stated that they offered to send him to the ER but he refused. Telephone interview with Resident #1 on 5/9/18 at 2:10 PM, revealed he was upset with how he was treated. He stated that he felt they didn't care about him and he told them if he couldn't get his medicine and he was hurting that he was going to leave. He stated that he asked the supervisor to call an ambulance so he could go to the hospital and that she told him you have a phone, you can call and get over there yourself and it wasn't an emergency. He stated that they didn't want to do anything to help him. He continued to say he did not get his medications especially his pain medication. During a telephone interview with the Nurse Practitioner on 5/9/18 at 2:40 PM, the Nurse Practitioner was asked about Resident #1 and did she receive a call from the nursing staff that he needed pain medication. The Nurse Practitioner stated, I don't have my computer up and I don't have my notes but they called me about a patient and it was a while back, but when they call about a patient, the hospital is supposed to send their scripts (handwritten prescriptions) with them, with the amount of issues with controlled substances of that nature, we don't write narcotics until you actually see that patient, so if they call and say we don't have the script, then the patient typically gets Tylenol until either I will tell them to call the hospital and ask them where's the script at, find the script so you guys can go pick it up and do it that way, but in the meantime there is a Tylenol ordered to give them a chance to maintain them until then. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered (Named Narcotic) to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night, because he was acting out. She was asked if she administered any other medications to him during his stay. She stated that she gave him one other medicine that morning at about 6:00 AM. LPN #1 was asked if she administered any other medications to Resident #1. She stated that she did not give him anything else because his medications had not come from the pharmacy yet. LPN #1 confirmed that she did borrow those 2 medications from other residents.",2020-09-01
462,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,658,D,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) nurses failed to follow the facility policy for administration of medications through an enteral tube and administration of eye drops. The findings included: 1. The facility's Medication Administration Enteral Tubes policy documented, .The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose .Enteral tubes are flushed with at least 15 ml (milliliters) of water before administering any medications and after all medications have been administered .PR[NAME]EDURES .Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in water .Dilute each liquid medication with water .Administer liquid medications first .Clean feeding syringe and return to bedside stand . Medical record review revealed Resident #18 was admitted to the facillity on 7/31/18 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 Tablet .1 time Daily .[MEDICATION NAME] 10 MG . GIVE 1 TABLET .ONCE DAILY .[MEDICATION NAME] .150 MG .TWICE DAILY .[MEDICATION NAME] ([MEDICATION NAME]) 5MG/ML .5 ML .EVERY 12 HOURS .FLUSH TUBE WITH 30ML H2O (water) BEFORE AND AFTER MEDICATION . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 administered an unmeasured amount of water, then poured in dry crushed [MEDICATION NAME], poured in an unmeasured amount of water, added dry crushed aspirin, added an unmeasured amount of water, added [MEDICATION NAME] solution without diluting, added an unmeasured amount of water, then added [MEDICATION NAME] liquid without diluting and followed with an unmeasured amount of water. LPN #1 did not measure the water and only poured a small amount of water following each medication. LPN #1 did not mix these medications with water prior to administering them through the enteral tube. Interview with the Director of Nursing (DON) on 12/19/18 at 12:00 PM, outside the Chapel, the DON was asked should enteral medications be diluted prior to administering in the enteral tube. The DON stated, Yes, they should . 2. The facility's Medication Administration Eye Drops policy documented, .With a gloved finger, gently pull down lower eyelid to form a pouch, while instructing resident to look up .Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye . Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].REFRESH TEARS 0.5% (percent) EYE DROPS .Give 1 Each in both eyes. As Needed .DRY EYES . Observations in Resident #73's room on 12/18/18 at 9:40 AM, revealed RN #1 administered eye drops without forming a pouch and held the bottle of medications above the eye and administered one drop over the center of the eye. Interview with the DON on 12/19/18 at 11:07 AM, at the East Nurses' Station, the DON was asked how should eye drops be administered. The DON stated, .form a pouch .",2020-09-01
463,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,686,D,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#47) sampled residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed a stage 2 pressure ulcer, stage 3 pressure ulcer and 1 suspected deep tissue injury (sDTI). The physician's orders [REDACTED].Order Date .9/11/2018 .BILATERAL HEEL BOOTS (Prevalon heel boots for prevention and treatment of [REDACTED]. The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Left heel stage 2 ruptured blister .Facility acquired .Length .0.3 .Width .0.3 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots . The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Right heel sDTI .Facility acquired .Length .0.0 .Width .0.0 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots .Sdtl .right heel has resolved .Prevalon boot remains in place for protection . Observations at the West Nurses' Station on 12/17/18 at 4:10 PM, revealed Resident #47 was sitting in a wheelchair only wearing one heel boot on her left foot. Wound care observations in Resident #47's room on 12/18/18 at 10:20 AM, revealed Resident #47 was in the bed lying on a special air mattress. Licensed Practical Nurse (LPN) #2 removed a non-skid sock from Resident #47's left foot. The wound area had a small scab with no drainage. A heel boot was on the resident's right foot, the wound area was dry and intact. Observations on 12/19/18 at 8:33 AM, revealed Resident #47 was dressed, sitting in her wheelchair by the bed, only wearing non-skid socks on both feet. Resident #47 was not wearing bilateral heel boots. Interview with LPN #4 on 12/19/18 at 9:38 AM, in Resident #47's room, LPN #4 was asked what Resident #47 was wearing on her feet. LPN #4 stated, Non-skid socks . LPN #4 was shown Resident #47's physician order [REDACTED].#4 then placed the heel boot on the resident's left foot and was unable to find the heel boot for Resident #47's right foot. Interview with the Director of Nursing (DON) on 12/19/18 at 9:00 AM, in the DON office, the DON was asked if staff should follow physician orders [REDACTED]. The DON stated, Absolutely .",2020-09-01
465,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,760,D,0,1,C6P811,"**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 were free of significant medication errors when 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses did not administer significant medications at the correct dosage. The findings include: 1. The facility's Medication Administration General Guidelines policy dated 5/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED].Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].(symbol for decrease) Losartan (a blood pressure medication) 25 mg (milligrams) po (by mouth) day (daily) . The Medication Administration Record [REDACTED].LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time (s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197. The failure of the nurse to administer the correct dose of losartan potassium resulted in a significant medication error. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 MG and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, .check Medication Administration Record, [REDACTED].",2020-09-01
468,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2017-08-08,226,D,1,0,IIH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to follow facility policy during an investigation of an allegation of abuse for 1 resident (#1) of 3 residents review for abuse. The findings included: Review of the facility's Policy and Procedure for Resident Abuse, last revised 11/6/11, revealed .any employee suspected of resident abuse .will be promptly removed of duty until the supervisor and/or administrator and abuse coordinator completes an investigation .nursing staff will thoroughly examine the resident for any signs of injury or abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a Nurse's Progress Notes dated 7/18/17 at 4:00 AM revealed .At 0300 (3:00 AM) CNA's (Certified Nurse Assistants) .entered room to change resident after small BM (bowel movement) .CNAs were administering peri-care when resident states 'they are hurting me' . (Licensed Practical Nurse (LPN) #4) and CNA entered the room to check on resident and resident stated 'I want my door closed because my private area has just been abused' .Notified abuse coordinator and investigation process stated (started) . Review of CNA #1 and CNA #2's time card report dated 7/18/17 revealed CNA #1 and CNA #2 left the facility at 6:23 AM (3 hours and 23 minutes after the allegation was made). Interview with the Director of Nursing (DON) on 8/7/17 at 3:20 PM, in the conference room, revealed she was not sure when the CNAs exited the facility. Telephone interview with LPN #4 on 8/7/17 at 3:44 PM confirmed CNA #1 and CNA #2 remained on the unit and continued to provide care to other residents during the investigation. Interview with the Administrator on 8/7/17 at 6:01 PM, in the conference room, revealed .talked to (Registered Nurse (RN) #1) .was told the CNAs were removed .CNAs not to do care .felt it (allegation of abuse) was not valid .if it were a situation where we immediately felt like resident were abused they'd be sent home immediately .I know they were not to perform care . Continued interview confirmed CNA #1 and CNA #2 were not removed from resident care during an investigation of an allegation of abuse and the facility failed to follow facility policy.",2020-09-01
470,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,571,D,1,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility admission packet, medical record review, review of trust transaction history, observation, and interview, the facility charged the personal fund account for incontinence care items for 1 resident (#72) of 34 incontinent residents reviewed of 44 sampled residents. The findings include: Review of the facility admission packet and resident rights revealed the facility would provide incontinence care supplies for the residents. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #72's Admission Record revealed the resident's primary payer source was Medicaid ICF (Intermediate Care Facility). Medical record review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #72's Brief Interview for Mental Status score was 15, indicating the resident was cognitively intact. Further review revealed the resident required supervision for all activities of daily living, was always continent of bladder, and occasionally incontinent of bowel. Medical record review of a social services note dated 8/23/18 revealed .Daughter and son have been requesting that a prescription be signed regarding (Resident #72's) briefs that she has been receiving from (medical supply company). I (social services) have spoken with (medical supply company), BCBS (insurance company), and her Choices CC (Medicaid Care Coordinator) and because she is in a long term care nursing facility, she can no longer receive the (disposable) briefs and her insurance be charged . Further review revealed the Medicaid insurance company told the facility they would not pay for the briefs because the resident was in a long term care nursing facility and .that is part of her care that we supply the briefs .if we send BCBS a bill for them to pay for her briefs, not only will they not pay for them but that is considered Medicaid fraud and we (facility) could face fraud charges for billing her insurance for something that we provide .(physician) will not sign the paper for this very reason and because the address is the sons address and she does not live with the son in the community. The son has been bringing the (disposable) briefs to (Resident #72) in the facility. The only reason why her insurance has been paying for the briefs is because the address is a community address and not the facilities . Continued review revealed the residents' daughter and son had been notified the resident's insurance would not pay for the briefs because the resident was in a long term care nursing facility. Review of Resident #72's Trust-Transaction History from 6/1/18-9/30/18 revealed $33.33 was withdrawn by the facility from the resident's trust fund on 9/14/18 for the cost of disposable briefs. Observation and interview with Resident #72 on 10/29/18 at 12:42 PM, in the resident's room, revealed the resident was wearing a disposable brief. Interview with the resident revealed the resident did not like the cloth briefs offered by the facility, and preferred disposable briefs. Interview with the Business Office Manager on 10/30/18 at 4:20 PM, in the Business Manager's office, confirmed Medicaid residents were charged for disposable briefs, or the facility would provide cloth briefs at no cost to residents who did not want to pay for disposable briefs. Continued interview confirmed the facility supplied disposable briefs for Medicare residents because the briefs were considered medical supplies for those residents.",2020-09-01
471,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,580,D,0,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain consent and notify the resident representative of changes to the psychiatric drug regimen of 1 resident (#82) of 5 residents reviewed for unnecessary medications of 44 residents sampled. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #82 was moderately cognitively impaired. Medical record review of the Order Listing Report, dated 10/31/18, revealed .[MEDICATION NAME] (antianxiety and antidepressant medication) 5 MG (milligrams) Give 1 tablet by mouth one time a day .Last Order Date .01/26/18 . Medical record review of the Psychiatric Progress Note, dated 1/26/18, revealed .Treatment Plan .1.) Start [MEDICATION NAME] 5 mg PO (by mouth) QDAY (daily) . Medical record review of the Psychiatric Progress Note dated 5/17/18, revealed .family wants patient taken off of [MEDICATION NAME] .upset that they never gave consent for it to be started 1/2018 . Medical record review of Resident #82's signed consents revealed no documentation of a signed consent, or verbal notification to the family, prior to the addition of [MEDICATION NAME] to the drug regimen on 1/26/18. Interview with the Director of Nursing (DON) on 10/31/18 at 3:55 PM, in the DON's office, confirmed there was no signed consent or documentation of notification to the resident representative of changes to the psychiatric drug regimen for Resident #82.",2020-09-01
472,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,644,D,0,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to refer to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review), after the resident was identified with a possible serious mental disorder, for 1 resident (#112) of 7 residents reviewed for PASARR. The findings include: Review of facility policy Admission Criteria, revised (MONTH) (YEAR), revealed .Any new psychiatric [DIAGNOSES REDACTED]. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the PASARR form dated 7/26/17 revealed Resident #112's [DIAGNOSES REDACTED]. Further review revealed the resident was negative for the level one screening, and if the nursing facility determined any inaccuracies in diagnoses, a Status Change review would be required. Medical record review of the [DIAGNOSES REDACTED]. Medical record review of a psychotherapy progress note dated 7/25/18 revealed the resident was sad, intermittently tearful, and expressed feelings of loneliness, hopelessness, and emotional isolation. Medical record review of the [DIAGNOSES REDACTED]. Interview with Minimum Data Set (MDS) nurse #1, responsible for completing PASARR's at the facility, on 10/30/18 at 8:36 AM, in the MDS office, revealed the most recent PASARR completed was on 7/26/17, prior to the addition of 2 mental health diagnoses. MDS nurse #1 stated another PASARR was completed for Resident #112 on 8/19/18 but .was canceled . MDS nurse #1 confirmed PASARRs had not been completed after the new mental health [DIAGNOSES REDACTED].",2020-09-01
475,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,600,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #3) of 6 residents reviewed for abuse, resulting in Resident #3 being hit by another resident. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/8/2019, showed .It is the organization's intention to prevent the occurrence of abuse . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . No injuries were noted. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 8/30/2019 and reviewed on 11/13/2019 revealed the resident had an intermittent [MEDICAL CONDITION] and would cuss at staff and make threats toward roommates. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. The resident had no behaviors during the look back period. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Care Plan dated 1/24/2020 showed Resident #1 was assessed for behaviors including verbal aggression toward others, including yelling and threatening others, and physical aggression toward others. Review of an admission MDS dated [DATE] showed the Resident #1 had short and long term memory problems and had exhibited verbal behaviors towards others 1-3 days during the look back period. During an interview on 2/19/2020 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated .(Resident #3) was upset .(Resident #1) was punching (Resident #3) on his head . During an interview on 2/19/2020 at 2:55 PM, CNA #2 stated .heard (Resident #3) hollering .went to check on him .(Resident #1) was hitting (Resident #3) .told him we can't hit other people . During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to prevent abuse to Resident #3.",2020-09-01
476,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,609,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's policy Abuse, Neglect and Misappropriation of Property, dated 5/8/2019, revealed .all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . The incident was reported to the State Survey Agency on 2/6/2020 at 4:14 PM (the next day). Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to report the incident to the State Survey Agency within 2 hours after the incident occurred. Refer to F-600",2020-09-01
477,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-06-12,600,D,1,0,TEPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interviews the facility failed to prevent abuse for 2 (#1 and #2) of 5 residents reviewed for abuse. The findings included: Review of the undated facility policy Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .willful means non-accidental .the individual must have acted deliberately, not that the individual must have intended to cause harm .If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/18 at 11:18 AM, via telephone, revealed I was in the East Wing Nurses Station across from the two residents; I was only about ten feet away from them. (Resident #2) came up to (Resident #1), and (Resident #1) asked (Resident #2) how he was doing. (Resident #2) replied he was coming to see what he was doing. I think he (Resident #1) said fine how are you? (Resident #2) replied he had come to look at the ladies, asses because he knew that was what (Resident #1) was doing. That upset (Resident #1), and (Resident #1) called (Resident #2) a Son of a [***] , at that point I stood up and said something like, now (Resident #1) don't talk like that, and he said I don't give a damn, I watched them for a minute, and then I started out from the nurses' station. I'm not sure who swung first, but they both began to swing at, and hit each other. Further interview confirmed based on what she had witnessed the two residents had intentionally hit each other. Interview with the Assistant Director of Nursing (ADON) on 6/11/18 at 3:32 PM, in the conference room, confirmed she had conducted the facility investigation, and based on interviews, and witness statements Resident #1 and Resident #2 had willingly and deliberately exchanged punches to each other, and the facility failed to prevent abuse of two residents.",2020-09-01
478,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2017-08-16,312,D,0,1,QGF311,"**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 provide assistance with oral care for 1 dependent resident (#63) of 3 residents reviewed for Activities of Daily Living (ADLs), of 21 residents sampled. The findings included: Review of the facility policy Oral Care, revised 6/1/15, revealed .A resident who appears to be able to care for self may be forgetting to care for teeth or dentures .Make sure resident removes dentures to clean .Make sure resident is brushing teeth and tongue . Medical record review revealed Resident #63 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 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with personal hygiene and oral care. Medical record review of Resident #63's Care Plan dated 7/20/15 revealed the resident was at risk for complications related to self care deficit. Medical record review of Certified Nursing Assistant (CNA) documentation of ADLs dated 4/1/17 to 8/16/17 revealed oral care had not been provided daily for Resident #63. Interview with Resident #63's family member on 8/14/17 at 11:28 AM, in the resident's room, confirmed the family member was providing oral care. I have to take care of .teeth, and I only come once or twice a week . Observation of Resident #63's mouth on 8/15/17 at 2:45 PM, in the resident's room, revealed the upper dentures were covered with debris in between the teeth. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/17 at 2:45 PM, in the resident's room, confirmed .Yeah, they look like they (dentures) need to be cleaned . Interview with Resident #63 on 8/16/17 at 10:12 AM, in the resident's room, confirmed staff had not assisted her with oral care on 8/16/17. Interview with Resident #63 and the family member on 8/16/17 at 1:16 PM, on the facility's porch, confirmed oral care had not been provided. Interview with the Director of Nursing (DON) on 8/16/17 at 2:01 PM, in the resident's room, confirmed oral care was not performed for Resident #63. Yes, it should be done everday and I expect them to do it . Continued interview confirmed the facility failed to provide oral care for Resident #63.",2020-09-01
479,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2017-08-16,441,D,0,1,QGF311,"Based on observation and interview, the facility failed to ensure handwashing was maintained for 1 of 4 Certified Nursing Assistants (CNAs) observed, during 1 lunch meal observed. The findings included: Observation of the main dining room on 8/14/17 from 12:00-12:12 PM, in the main dining room, revealed CNA #1 placed trash in the covered trash can, proceeded to a female resident at a table in the middle of the dining room, touched the resident and resident's eating utensil, then touched and greeted the other resident at the table, The CNA proceeded to a resident at the next table, touched her and her utensils, then sat down and assisted the resident by cueing and feeding bites of food to her. Interview with CNA #1 on 8/14/17 at 12:15 PM, in the main dining area, confirmed the CNA had not washed hands between contact with the 3 residents observed. Interview with the Director of Nurses (DON) on 8/14/17 at 2:40 PM, in the conference room, confirmed handwashing was required between contact with residents. Interview with the DON on 8/15/17 at 3:30 PM, in the conference room, confirmed the facility did not have a formal method for auditing handwashing compliance and the DON had made casual observations only.",2020-09-01
481,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,677,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility documentation review, and interview, the facility failed to provide assistance with bathing to maintain personal hygiene for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Continued review revealed the resident required extensive assistance with toileting, and personal hygiene. Review of a facility document, Bathing Report, dated 7/20/18 through 8/6/18, revealed no documentation Resident #1 received scheduled showers on 7/19/18, 7/23/18, 7/28/18, or 8/4/18. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room confirmed the facility failed to provide assistance with bathing for 4 of 7 scheduled showers.",2020-09-01
482,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,684,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to provide 1 antipsychotic medication and 1 antianxiety medication as ordered for 1 resident (#9) of 3 residents reviewed. The findings include: Review of the facility policy, Medication Administration Guidelines, dated 5/16 revealed .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time . Medical record review revealed Resident #9 was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of the Physician Order Sheet dated 9/7/18, revealed .[MEDICATION NAME] .5 mg Tablet by mouth three times a day .Ziprasidone HCL 80 mg twice daily . Review of the Medication Administration Record [REDACTED].Ziprasidone HCL 80 mg (milligram) give one cap (capsule) by mouth twice a day with food .16:00 (4:00 PM) and AM . with no documentation the medication was administered at 4:00 PM on 9/7/18. Continued review revealed .[MEDICATION NAME] .5 mg Tablet Give one tab (tablet) by mouth three times a day 6:00 (AM), 14:00 (2:00 PM), 20:00 (8:00 PM) with no documentation the medication was administered at 2:00 PM or 8:00 PM on 9/7/18. Interview with Licensed Practical Nurse (LPN) #6 on 9/12/18 at 12:00 PM, in the conference room, confirmed she had not given Resident #9 his 8:00 PM, dose of .5 mg of [MEDICATION NAME] (antianxiety medication). I figured his medication would be here soon and I would give it then. I didn't think a .5 mg of [MEDICATION NAME] would make much difference. I did not attempt to obtain the medication from the E-box (emergency box) or contact the pharmacy. Interview with LPN #3 on 9/12/18 at 12:40 PM, in the conference room, confirmed Resident #9's [MEDICATION NAME] and Ziprasidone HCL (antipsychotic medication) had not been delivered to the facility by the pharmacy at the time they were scheduled to be administered. Continued interview confirmed she did not administer Resident #9 a scheduled 2:00 PM dose of .5 mg [MEDICATION NAME] or his 4:00 PM scheduled dose of 80 mg Ziprasidone HCL. Continued interview confirmed LPN #3 did not attempt to obtain the 2:00 PM, dose of .5 mg [MEDICATION NAME] from the E-box. Interview with the Director of Nursing on 9/12/18 at 4:10 PM, in the conference room, confirmed Resident #9 did not receive his 4:00 PM scheduled dose of Ziprasidone 80 mg, and did not receive his 2:00 PM and 8:00 PM dose of .5 mg [MEDICATION NAME]. Continued interview revealed it was her expectation if a medication was unavailable for a resident the Physician was to be notified for a new order. Continued interview confirmed they had access to a local pharmacy, and [MEDICATION NAME] was available in the E-box, but had not been utilized. Further interview confirmed the facility failed to provide Resident #9 his medications as ordered.",2020-09-01
483,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,692,D,1,0,9GQL11,"**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 follow a recommendation from the Registered Dietitian for an oral Nutritional Supplement for weight loss for 1 resident (#1) of 3 residents reviewed for weight loss. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of a facility document, Weights, revealed Resident #1's weight on 7/23/18 was 220.4 pounds, and on 7/31/18 was 211.8 pounds, indicating a weight loss of 8.6 pounds or 3.9% in 8 days. Review of a Nutrition Note dated 8/1/18, revealed .Res (resident) obese/[MEDICAL CONDITION] and wt. (weight) Review of the Medication Administration Record [REDACTED] Review of Physician Telephone Orders dated 8/1/18 through 8/6/18, revealed no order for Med pass 90 ml TID. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room, confirmed Resident #1 did have weight loss during admission. Continued interview confirmed the Registered Dietitian's recommendation on 8/1/18 for Med Pass 90 ml 3 times daily was not followed and facility failed to provide the recommended oral supplement for weight loss.",2020-09-01
484,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,638,D,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an annual Minimum Data Set (MDS) for 1 resident (#1) of 25 residents reviewed. The findings include: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS history, revealed Resident #1 had an entry MDS assessment completed on 3/26/18, a quarterly assessment was completed on 4/13/18, and no further assessments were noted in the system. Telephone interview with the Clinical Reimbursement Consultant on 9/19/18 at 5:10 PM, confirmed an annual MDS with an assessment reference date of 7/14/18, was initiated and not completed, and no further assessments have been completed for Resident #1.",2020-09-01
485,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,656,D,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to revise the Comprehensive Care Plan to address post fall interventions for 1 resident (#22) of 25 residents reviewed. The findings include: Review of the facility's Falls Policy Statement, undated, revealed .If a fall occurs the following actions will be taken: Update care plan . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required maximum to total assistance with all activities of daily living, and had previously fallen. Medical record review of the Nursing Assessment for description of falls and the post fall interventions initiated dated: on 4/12/18 revealed the resident fell out of bed, and the post fall intervention was to assess the resident's normal routines; 4/30/18 the resident fell from the wheel chair, and the post fall intervention was to offer to assist the resident to bed after the evening meal; 5/14/18 the resident fell from the bed, and the post fall intervention was to monitor pain, place fall mats next to bed; 5/18/18 the resident fell from the bed, and the post fall intervention was to place fall mats to both sides of the bed; 6/12/18 the resident fell from the wheel chair, and the post fall intervention was to remove the wheel chair foot rests; 6/29/18 the resident fell from the bed, and the post fall intervention was to place fall mats next to the bed; 7/31/18 the resident fell from the bed, and the post fall intervention was to keep the resident close to the nurse's station; and on 8/5/18 the resident fell from the wheel chair, and the post fall intervention was to keep the resident close to the nurse's station and to assess the resident's routines. Medical record review of the Comprehensive Care Plan dated 4/17/18 revealed .At risk for fall related injury .assist resident with transfers as needed .anticipate resident needs .monitor for pain . with no further interventions to prevent further falls. Observation of Resident #22 on 9/17/18 to 9/19/18 at various times from 8:00 AM to 5:00 PM, revealed the resident was in the bed with a curved mattress, was very restless, but made no attempts to climb out of the bed. Interview with the Interim Director of Nursing on 9/19/18 at 7:25 PM, in the conference room, confirmed Resident #22's Comprehensive Care Plan had not been revised to address the post fall interventions.",2020-09-01
486,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,758,D,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications for 1 resident (#38) of 5 residents reviewed for unnecessary medications of 25 residents sampled. The findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #38 was easily annoyed and rummages through items, received antipsychotic, antidepressant, and antianxiety medications 7 days each week, and no GDR had been attempted. Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the monthly pharmacist reviews, revealed the pharmacist initialed each month the resident's medications were reviewed, with no recommendations for GDR of [MEDICAL CONDITION] medications. Observation on 9/19/18 at 2:30 PM, on the secure unit revealed Resident #38 was seated at the table in the day area with a busy cloth (promotes self-directed activity). Continued observation revealed the resident was calm and observed the activity taking place. Interview with the Corporate Regional Nurse on 9/19/18 at 5:30 PM, in the conference room confirmed no GDRs of Resident #38's [MEDICATION NAME], and [MEDICATION NAME] had been attempted since the resident's admission to the facility on [DATE].",2020-09-01
488,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,880,D,0,1,W7N711,"Based on review of facility policy, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 1 unit of 3 units observed for dining, and failed to perform proper hand hygiene after providing peri-care for 1 resident of 2 residents observed for peri-care. The findings include: Review of the facility policy, Handwashing/Hand Hygiene, revised 8/2015 revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .Before and after assisting a resident with meals .After contact with objects (e.g., (for example) medical equipment} in the immediate vicinity of the resident .After removing gloves . Observation on 9/17/18 from 1:00 PM-1:07 PM, on the Harriman Unit revealed Certified Nursing Assistant (CNA) #2 delivered a lunch tray to Resident #29 in the resident's room, moved the resident's bedside table and exited the room without performing hand hygiene; CNA #2 then delivered a lunch tray to Resident #62, moved the resident's bedside table, touched the resident's bed and the privacy curtain, and exited the room without performing hand hygiene; CNA #2 proceeded to deliver a lunch tray and pour coffee for Resident #42, and exited the room without performing hand hygiene. Further observation revealed CNA #2 delivered a lunch tray to Resident #58, moved a soiled shirt from the bedside table, touched the linen on the resident's bed, moved the resident's bedside table, touched the call light which was laying on the bedside commode, placed the soiled clothes in a plastic bag, and carried the soiled clothes to the soiled utility room. Continued observation revealed CNA #2 did not perform hand hygiene and proceeded to the cart to retrieve another tray. Interview with CNA #2 on 9/17/18 at 1:07 PM, on the Harriman hallway, confirmed CNA #2 had failed to perform hand hygiene between residents and after contact with objects in the resident's rooms during the lunch meal tray pass. Interview with the Interim Director of Nursing (DON) on 9/17/18 at 3:00 PM, in the hall outside of the DON's office, confirmed staff was expected to perform hand hygiene between residents during the meal tray pass and after touching objects in the resident's room. Observation on 9/19/18 at 3:48 PM, in a resident's room of Certified Nursing Assistant (CNA) #1 providing peri-care for a resident revealed after CNA #1 completed the peri-care, the CNA touched the resident's blanket to place the blanket over the resident, repositioned the call light, and washed the bedpan, and then removed the contaminated gloves. Continued observation revealed CNA #1 did not perform hand hygiene after she removed the contaminated gloves, donned one new glove, and adjusted the resident's head of the bed. Interview with CNA #1 on 9/19/18 at 3:55 PM, on the Harriman hallway, confirmed she had not removed the contaminated gloves and performed hand hygiene after providing resident care prior to donning one new glove. Interview with the Interim Director of Nursing on 9/19/18 at 5:10 PM, in the conference room confirmed the facility failed to follow their facility policy regarding hand hygiene after resident care and before donning new gloves",2020-09-01
489,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2019-10-16,656,D,0,1,RL5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to revise the care plan to include the use of the back and collar brace for 1 resident (#35) of 25 residents reviewed for care plans. The findings include: Review of the facility policy, Comprehensive Care Plans, revised 7/19/18, revealed .Each resident's Comprehensive Care Plan is designed to .incorporate identified problem areas; incorporate risk factors associated with identified problems . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #35's Current Comprehensive Care Plan, dated 6/28/19, revealed no documentation of the back and collar brace. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment, and was unable to complete the interview. Medical record review of Physician Order Report revealed .7/11/19 .Back and collar brace .Special Instructions: Resident needs to wear her back and collar brace . Observation of Resident #35 on 10/14/19 at 2:46 PM, in the main dining room revealed Resident #35 was smiling and engaged in a group bingo activity. Interview with the Unit Manager (UM) #1 on 10/15/19 at 2:42 PM, confirmed she was unaware of the brace. Further interview confirmed it was UM #1's responsibility to apply the brace. Interview with Corporate Nurse #1 on 10/16/19 at 9:13 AM, in the conference room, confirmed it was her expectation that the brace intervention be care planned. Further interview confirmed the brace was not included on Resident #35's Current Comprehensive Care Plan .it's not on there .",2020-09-01
490,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2019-10-16,689,D,0,1,RL5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of the facility's falls documentation, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to complete a fall risk assessment, and failed to complete a fall investigation for 1 resident (#70) of 3 residents reviewed for accidents. The findings include: Review of the facility Falls Policy, dated 7/16/19, revealed .All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .If a fall occurs the following actions will be taken .Evaluate resident .Document the evaluation, pertinent facts and incident . Medical record review revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #70's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had severe cognitive impairment. Continued review revealed the resident required extensive assist of 1 staff member for bed, transfer, and dressing. Medical record review of Resident #70's Fall Risk Assessment, dated 3/21/19, revealed a score of 24, a score of 10 or greater, indicated the resident was at high risk for falls. Review of the facility Falls Investigation, dated 4/18/19, revealed Resident #70 had a fall without injury. Review of a facility Falls Investigation, dated 6/20/19, revealed .Fall without injury . Continued review revealed the fall investigation had not been completed. Medical record review of Resident #70's Fall Risk Assessment, dated 7/18/19, revealed a score of 18, a score of 10 or greater, indicated the resident was at high risk for falls. Review of a facility Falls Investigation, dated 8/20/19, revealed the resident had an unwitnessed fall without injury. Medical record review of the Comprehensive Care Plan dated 9/19/19, revealed a new fall intervention had not been implemented after the falls on 6/20/19 and 8/20/19. Medical record review of the Fall Risk Assessment revealed a quarterly falls risk assessment had not been completed for 9/24/19. Observation of Resident #70 on 10/15/19 at 7:40 AM, in the residents room, sleeping in bed. Interview with the Interim Director of Nursing on 10/16/19 at 12:05 PM, in the conference room, confirmed the facility failed to follow their falls policy, failed to complete a falls investigation, failed to complete falls risk assessments and failed to implement appropriate falls interventions to prevent falls for Resident #70.",2020-09-01
491,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,600,D,1,0,CEZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 (Resident #2) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Program Updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Continued review revealed the resident exhibited no behaviors during the review period. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] for Resident #2 revealed the resident was rarely/never understood. Continued review revealed no behaviors were exhibited during the review period. Observation on 2/12/18 at 10:25 AM, of Resident #2, in her room on the secure unit revealed the resident seated on the side of her bed. Continued observation revealed the resident was awake and alert, however did not answer questions appropriately. Review of the facility investigation dated 1/19/18 revealed .At 12:53 PM (Resident #2) was struck four times on the left shoulder by (Resident #9) after she wondered into his room .Upon attempting to enter (resident #9's) room, she (Resident #2) backed out; he followed her out, and then struck her four times on the left shoulder with an open hand . Review of a Progress Note dated 1/19/18 at 3:06 PM, for (Resident #3) revealed .Resident opened door to (Resident #9's) room attempting to enter. Resident began backing out of room at which time (Resident #9) struck 3-4 times making contact to left shoulder . Interview on 2/14/18 at 12:00 PM, with[NAME]Lowhorn DON, in the conference room confirmed Resident #9, did willfully hit Resident #2 in attempt to remove her from his room, and the facility failed to prevent abuse for one resident #2.",2020-09-01
493,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2019-06-11,609,D,1,0,MC9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, and interviews, the facility failed to report an injury of unknown injury involving bodily injury for 1 resident (#1) of 3 residents reviewed for injuries of unknown origin. The findings include: Review of facility policy Abuse Prevention Policy Updated 1/19/17 revealed .All personnel must promptly report any incident of resident abuse, mistreatment or neglect, including injuries of unknown origin .when the source of the injury was not observed or known by any person . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed Resident #1 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status. Medical record review of a nursing progress note dated 5/27/19 at 3:16 PM revealed .c/o (complains of) increased pain to right hip .(named physician) informed .received a new order to obtain right hip x-ray . Medical record review of a Mobile Radiology Report dated 5/27/19 revealed .There is a right hip hemiarthroplasty in normal position. A moderately displaced [MEDICAL CONDITION] trochanter is present. Surgical staples are present in the proximal right thigh laterally. No other fracture dislocation or other abnormalities of the right hip are present .Conclusion .Displaced [MEDICAL CONDITION] trochanter, new . Interview with Licensed Practical Nurse (LPN) #2 on 6/10/19 at 4:20 PM, in the conference room, revealed .on 5/27/19 she (Resident #1) started having some hip pain even with her PRN (as needed) medication .she had started to complain of pain in her hip, her medication was not as effective as it had been. I called the doctor and told him and he ordered a right hip x-ray .I am not aware of anything out of the ordinary occurring, the only thing different was an increased complaint of pain. No one reported anything from any shift (increased pain or injury) . Telephone interview with LPN #2 on 6/11/19 at 9:40 AM revealed .when I came in on the 27th around 6:30 PM .(LPN #1) reported .(Resident #1) had complained of increased pain and the x-ray technician was here .I picked up the x-ray results off the fax early on the 28th and passed them to the day shift nurse .during the night she never complained of pain .and there weren't any non-verbal signs of pain or any discomfort .I am not aware of anything happening, any incidents or a fall that would have attributed to the fracture. I know now I should have checked the fax machine and reported the results immediately . Interview with the Director of Nursing (DON) on 6/11/19 at 11:25 AM, in the conference room, revealed .on Tuesday morning about 10:30 AM, I was notified of the x-ray results of a lesser trochanter fracture on (Resident #1's) right side. I immediately started an investigation .during the interviews with staff no one was aware of any incidents or occurrences that would have attributed to a fracture. I was not able to identify anything indicating abuse/neglect or concerns related to quality of care . Continued interview confirmed the x-ray was obtained at approximately 6:30 PM on 5/27/19 and the x-ray report was faxed to the facility on [DATE] at approximately 7:00 AM. Further interview revealed the DON was notified of the results at approximately 10:30 AM and .I should have been notified immediately when the results were reviewed by the nurse at 7:00 AM . Continued interview confirmed the facility failed to report an injury of unknown origin timely to the State survey agency and the facility failed to follow facility policy.",2020-09-01
494,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,159,D,0,1,0D6Y11,"Based on review of facility policy, review of the trial balance for resident trust funds, and interview, the facility failed to make trust funds available on the week-end for 1 resident (#78) of 15 residents interviewed. The findings included: Review of the facility policy titled, Resident Trust issued: 10/20/15, included under the section: Procedure, numbered 1 through 12. Review of procedure 6. Banking Times will be posted and access to resident funds will be available on Saturday and Sunday during banking hours. Those residents wishing to withdraw or deposit money may do so at these times. Observation on entrance revealed there was no posting of banking hours on 6/19/17 or on 6/20/17. Interview of Resident #78, on 6/19/17 at 4:19 PM, revealed he does have a personal funds account with the facility. Resident #78 stated he is not able to withdraw funds from his account on the week-ends. You can only get money when the business office is open and she works Monday thru Friday. A sign posted on 6/21/17 outside the door of the business office included the following information: Resident Trust Banking Hours Monday through Friday from 9am to 5pm Interview of Business Office Manager (BOM), at 7:45 a.m. on 6/21/17, verified the residents had no access to funds on Week-ends. We have nothing in writing or posted in regards to time to access funds from personal accounts. The BOM stated she was aware that residents should have access to funds on the week-ends but she just hadn't implemented a program.",2020-09-01
496,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,309,D,0,1,0D6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#80) of 4 residents reviewed for weight loss, of 34 residents reviewed. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated 6/1/17 revealed XXX[AGE] year-old .female, who comes to the hospital because of severe swelling all over, shortness of breath (SOB) .She was known to have jugular venous distention, bilateral [MEDICAL CONDITION] .She had been recently admitted 9 days prior from .a fall where she had rib fracture and the effusion in her chest has apparently worsened .Exertion makes her shortness of breath worse, rest and oxygen makes it better .Impression: 1. [MEDICAL CONDITION] . Medical record review of a physician's order dated 6/2/17 revealed Daily weights for [MEDICAL CONDITIONS] in the morning . Medical record review of the Weights and Vitals Summary revealed the following: on 6/6/17 weight recorded as 223 lbs. (pounds) via wheelchair; on 6/7/17 weight recorded as 220.4 lbs. via mechanical lift; on 6/8/17 weight recorded as 220.4 lbs. via wheelchair; on 6/10/17 weight recorded as 212.4 lbs. via mechanical lift; on 6/11/17 weight recorded as 207 lbs. via mechanical lift; on 6/12/17 weight recorded as 203.6 lbs. standing; on 6/13/17 weight recorded as 198.6 lbs. via mechanical lift; on 6/14/17 weight recorded as 197 lbs. via mechanical lift; on 6/17/17 weight recorded as 197 via bedscale; and on 6/20/17 weight recorded as 165.4 lbs. via mechanical lift. Medical record review of a nursing note dated 6/8/17 revealed Assessment: Resident cont (continues) to have +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities), crackles to lower ls (?lungs), Dr .notified, new order for [MEDICATION NAME] 80mg bid (twice a day), Potassium 20 meq bid, Resident alert with confusion at times, able to make needs known .Resp (respirations) even non labored, SOB noted when laying flat .HOB (head of bed) elevated .poor appetite noted this shift . Observation on 6/20/17 at 12:40 PM revealed the resident lying on the bed with the HOB elevated with the spouse at bedside. Interview with the Director of Nursing (DON) on 6/20/17 at 4:20 PM, in the DON's office revealed 1 of the weights obtained on 6/17/17 or 6/20/17 was not accurate and the weight on 6/17/17 was documented as being obtained via a bedscale was not accurate because the facility did not have a bedscale. Continued interview revealed the Restorative Aide did all the weights in the facility when she was working. Further interview revealed the same type of scale needed to be used consistently, and if a different scale needed to be used for individual residents a reason for the change in the type of scale used needed to be documented. Further interview confirmed daily weights were not obtained for Resident #80 on the following dates: 6/3/17, 6/4/17, 6/5/17, 6/9/17, 6/15/17, 6/16/17, 6/18/17, and 6/19/17 (8 of 18 opportunities from 6/3/17-6/20/17).",2020-09-01
499,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,441,D,0,1,0D6Y11,"Based on facility policy review, observation and interview, the facility failed to follow infection control procedure per policy in the decontamination of a blood glucose monitor devise between the use on 2 residents (#61 and #99) out of 5 residents on the D unit of the facility, of 34 residents reviewed. The findings included: Review of the facility policy titled Blood Glucose Monitor Decontamination with an effective date 05/05/2016 revealed A wipe that is an EPA (environmental protection agency) registered as tuberculocidal; effective against HIV (humane immunosuppressant virus), HBV (Hepatitis B virus) and broad spectrum of bacteria will be utilized to clean the monitor. It is 0.525% sodium hypochlorite which is equivalent to a 1:10 bleach dilution solution, and meets recommendation for use on equipment from Clostridium difficile rooms (such as Clorox germicidal wipes). If a product wipe is not available a 1:10 bleach solution may be substituted. Policy: The blood glucose monitor will be cleaned and disinfected with wipes following use on each resident (when monitors are shared by multiple residents) or at the times designated on Individual Blood Glucose Monitor Decontamination Policy (for residents with assigned monitor). Procedure: 1. After performing the glucose testing, the nurse, wearing gloves, will use a disposable wipe to clean all external parts of the monitor. 2. Leave monitor damp for maximal kill time indicated on product label. If the monitor begins to dry before maximal kill time, use another wipe for the total dampness kill time indicated on product label. 3. Place clean monitor on a clean surface. 4. If a dried salty residue remains once dry, simply wipe with a clean cloth to remove. 5. Remove gloves and perform hand hygiene. 6. Return monitor to cart or other clean storage area. 7. Please be sure to keep the wipe away from the meter strip portal. Observation of medication administration on 6/20/17 at 11:29 AM, for Resident #99, revealed Licensed Practical Nurse (LPN) #1 to remove the glucose monitor device out of her uniform pocket and placed the glucose monitor on top of the resident table. LPN #1 used a disposable lancet devise to obtain a blood sample. The blood sample was placed on the test strip which was inserted into the end of the glucose monitor. The nurse disposed of the lancet device and strip to the sharps container. LPN #1 returned to the medication cart and placed the dirty glucose monitor on top of medication cart. No barrier was used to protect the top of the medication cart from the contaminated glucose monitor. LPN #1 opened an alcohol wipe and wiped off the meter and placed it back on top of medication cart. At 11:47 AM LPN #1 picked up the same glucose monitor used on Resident #99 and went into the room of Resident #61. LPN #1 placed the glucose monitor on the resident's bedside table without a barrier. LPN #1 obtained the blood sample from Resident #61 using a disposable lancet devise. The blood sample was placed on the test strip and inserted in the end of the glucose monitor devise. The test strip and lancet devise were disposed of in the sharps container. LPN #1 returned to the medication cart and wiped the glucose monitor with an alcohol wipe and placed the glucose monitor back in the medication cart drawer. No barrier was used to protect supplies in the mediation cart drawer from contamination from the glucose monitor that was not cleaned properly. Interview with LPN #1, on 6/20/17 at 11:55 AM revealed I use alcohol wipes between residents to clean the glucose monitor and at the end of my shift I would clean with a bleach wipe. Continued interview confirmed confirmed the glucose monitor was cleaned with alcohol and no barrier was used in resident rooms or on top of medication cart or in the drawer of the medication cart to prevent cross-contamination by the glucose monitor.",2020-09-01
500,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,520,D,0,1,0D6Y11,"Based on review of facility policy, review of the Quality Assurance and Performance Improvement (QAPI) committee attendance records, and interview the facility failed to hold a formalized meeting quarterly. The findings included: Review of the facility's policy QAPI, undated, revealed .The QAPI Committee shall look for opportunities for improvement on a continuous basis, and promote an environment of CQI-Continuous Quality Improvement environment analyze data monthly to identify opportunities for improvement .The Committee will make recommendations, and hold a formalized meeting at a minimum of quarterly . Review of the facility's QAPI committee attendance records revealed a quarterly QAPI meeting was conducted on 12/9/16 and the next QAPI meeting was not conducted until 4/28/17. Interview with the Administrator on 6/21/17 at 11:00 AM in the Administrator's office confirmed the facility had a QA meeting on 12/9/16 and 4/28/17. Further interview confirmed the facility did not hold a formalized meeting quarterly between 12/9/16 and 4/28/17.",2020-09-01
501,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,689,D,0,1,R2J911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure a new falls intervention was implemented after a fall for 1 resident (#28) of 3 residents reviewed for accidents of 30 sampled residents. The findings include: Review of the facility policy, Incidents/Accidents/Falls, undated revealed .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved .All falls will have a site investigation by appropriate staff .Each fall needs a new intervention rolled out . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility, dressing, tranfers and toileting. Medical record review of facility documentation dated 2/9/18, revealed .Pt (patient) hit the emergency light in bathroom; had ambulated w/o (without) calling for assistace .pt was on her knees on the floor .negative for any new injuries . Medical record review of the care plan revealed .2/8/18 fall in room. No injuries . Continued review revealed no new intervention was implemented after the fall on 2/8/18. Interview with the Assistant Director of Nursing on 9/6/18 at 9:00 AM, in the conference room, confirmed the facility failed to follow their policy and failed to implement a new intervention to prevent further falls for Resident #28.",2020-09-01
502,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,692,D,0,1,R2J911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to ensure a resident was reevaluated by a Registered Dietician (RD) after a significant change for 1 resident (#28) reviewed for nutrition of 30 sampled residents. The findings include: Review of the facility policy,Screening and Initial Evaluation, undated revealed . A nutritional assessment is completed at least annually .New admits, Annuals and those Resident's with significant changes will be placed on the list for the RD (Registered Dietician) to see on their next visit. The Registered Dietician will review the assessment completed by the DM (Dietary Manager), and complete an in depth nutritional assessment upon admission or significant change would warrant an in depth assessment sooner. Any other resident who is deemed high risk such as those with .[MEDICAL TREATMENT] .will be placed on the list for the RD to review at their next visit .A quarterly note will be entered into the health record by the Dining Services Manager (Dietary Manager) .no less that quarterly .The care plan will be updated as changes are made in nutritional interventions as they occur . Medical record review revealed Resident #28 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 a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, had a weight loss of 5% or more and was receiving [MEDICAL TREATMENT]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Medical record review of the resident's weight dated 11/3/17 (previous admission) revealed a weight of 122 pounds (lbs). Continued review revealed a readmission weight on 12/23/17 was 92.2 lbs (a decrease of 29.8 lbs) Medical record review of a Registered Dietician assessment dated [DATE] revealed .Screening Factors from MDS .Below desired weight range .Poor intake/Potential Medical record review of a RD progress noted dated 12/28/17 revealed .New Re-Admit .with [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]), dysphagia .anorexia, dehydration, N/V (nausea/vomiting) .CBW (current body weight) 92.2 # (pounds) .BMI .16.9 (suboptimal for age/clinical status) .Ideal body wt (weight) .115# . Medical record review of a Physicians order dated 1/8/18 revealed an order to admit for Resident #28 for hospice services. Medical record review of a Hospice note dated 2/9/18 revealed discontinue weights per hospice for comfort. Interview with the Director of Food Services (Dietary Manager) on 9/6/18 at 10:00 AM, outside the kitchen, confirmed he was not aware until recently that he was responsible for documenting quarterly notes on residents. Continued interview confirmed he did not complete any quarterly notes on Resident #28. Interview with the Director of Nursing on 9/6/18 at 1:30 PM, in the conference room confirmed the facility failed to follow their policy and failed to ensure Resident #28 was re-evaluated quarterly by the RD and Director of Food Services.",2020-09-01
503,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,761,D,0,1,R2J911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired blood collection tubes were properly disposed of in 1 of 1 storage rooms. The findings include: Observation of the A hall storage room, with Registered Nurse (RN) #1, on [DATE], at 12:05 PM, revealed the following: 97 expired blue top blood collection tubes expired [DATE]. Interview with RN #1, on [DATE], at 12:06 PM, in the A hall storage room confirmed the blood collection tubes were expired and available for resident use.",2020-09-01
504,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2020-01-09,554,D,0,1,PNLU11,"**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 1 of 4 nurses (Licensed Practical Nurse (LPN) #1) remained with a resident during an inhalation treatment for 1 of 10 sampled residents (Resident #32) observed during medication administration. The findings include: The facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010 documented, .Remain with the resident for the treatment . Review of the medical record, showed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] SUL (Sulfate) 1.25 MG (milligram)/ (per) 3ML (milliliters) SOL. (solution) GIVE ONE PER NEBULIZER EVERY 4 HOURS . Observation in the resident's room on 1/7/20 at 8:06 AM, showed LPN #1 administered the [MEDICATION NAME] nebulizer treatment to Resident #32. LPN #1 left the room and was absent during the entire treatment. The facility was unable to provide a self-administration assessment for nebulizer treatments for Resident #32. During an interview conducted on 1/8/20 at 4:07 PM, the Director of Nursing confirmed the nurse should stay with the resident during the breathing treatment unless the resident has had a self-administration assessment.",2020-09-01
505,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2020-01-09,637,D,0,1,PNLU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 18 sampled residents (Resident #56) reviewed. The findings include: Review of the medical record, showed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Order Date 10/10/19 .Start Date 10/10/19 .ADMIT TO HOSPICE SERVICES WITH (Named Hospice Company) . Review of the medical record, showed there was no Significant Change MDS assessment completed when Resident #56 was referred to hospice services. During an interview conducted on 1/6/20 at 2:15 PM, the MDS Coordinator confirmed Resident #56 should have had a significant change MDS assessment done when hospice services were ordered.",2020-09-01
507,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,656,D,0,1,U7IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to prevent accidents related to falls for 1 of 12 (Resident #30) residents when fall interventions were not implemented. The findings include: The facility's Falls and Fall Risk, Managing policy revised on 3/2018 documented, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/1/17 documented, .9/24/18 Rojo (pressure relieving) cushion to wheelchair .12/26/18-Educate R/T (related to) proper cushion and placement in w/c (wheelchair) .1/14/19 Fall-Ensure dysem is in w/c (wheelchair) staff education . Review of the facility's Resident Incident Report dated 12/26/18 documented, .leaning forward and slid out .wc (wheelchair) .cushion eval (evaluated) improper cushion in place .new Rojo (pressure relieving cushion) being ordered .a fall without injury . Review of the facility's Resident Incident Report dated 1/14/19 documented, .found lying on floor in front of wheelchair .care planned to have dycem to wc (wheelchair) .was not present .no injury . Interview with the Director of Nursing (DON) on 2/21/19 at 3:58 PM, in the Family Room, the DON was asked if the interventions were in place for Resident #30's falls on 12/26/18 and 1/14/19. The DON stated, No, they were not in place.",2020-09-01
508,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,689,D,0,1,U7IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 12 (Resident #30) residents were free from accident hazards by not implementing the interventions for falls. The findings include: 1. The facility's Falls and Fall Risk, Managing policy revised on 3/2018 documented, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/1/17 documented, .9/24/18 Rojo (pressure relieving) cushion to wheelchair .12/26/18-Educate R/T (related to) proper cushion and placement in w/c (wheelchair) .1/14/19 Fall-Ensure dysem is in w/c (wheelchair) staff education . The Significant Change and Quarterly Minimum Data Set ((MDS) dated [DATE] and 12/28/18 documented 2 falls with no injury. Review of the facility's Resident Incident Report dated 12/26/18 documented, .leaning forward and slid out .wc (wheelchair) cushion eval (evaluated) improper cushion in place .new Rojo (pressure relieving cushion) being ordered .a fall without injury . Review of the facility's Resident Incident Report dated 1/14/19 documented, .found lying on floor in front of wheelchair .care planned to have dycem to wc (wheelchair) .was not present .no injury . Interview with the Director of Nursing (DON) on 2/21/19 at 3:58 PM, in the Family Room, the DON was asked if the Rojo cushion was in place for the fall on 12/26/18 and if the dycem cushion was in place for the fall on 1/14/19. The DON stated, No, they were not in place.",2020-09-01
509,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,693,D,0,1,U7IF11,"Based on policy review, observation, and interview the facility failed to ensure correct placement for the Percutaneous Endoscopic Gastrostomy (PEG) before administering medication when 1 of 6 (Licensed Practical Nurse (LPN)#1) failed to check placement. The findings include: The facility's Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .check placement . Observation in Resident # 16's room on 2/19/19 beginning at 2:40 PM, LPN #1 did not check placement of the PEG tube before administering medications. Interview with the Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked do you expect placement to be checked before administering medication through a PEG tube, the DON stated, .yes .",2020-09-01
510,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,760,D,0,1,U7IF11,"**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 residents were free from significant medication error when 1 of 6 (Licensed Practical Nurse (LPN)#1) nurses failed to administer the correct dose of Tegretal, an anticonvulsant medication. The findings include: 1. The facility's Administering Medications through an Enteral Tube Administration policy revised (MONTH) (YEAR) documented, .correct dose of medication .confirm placement of feeding tube .Administer medication . 2. Medical record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 200 MG (milligram). GIVE ONE TABLET BY PEG (Percutaneous Enteral Gastrostomy) TUBE THREE TIMES DAILY . 3. Observations during medication administration on 2/19/19 beginning at 2:40 PM, in Resident #16's room. LPN #1 had crushed the [MEDICATION NAME] and diluted the medication with water. LPN #1 did not check placement of the PEG tube. LPN #1 flushed the PEG tube with 30 milliters of water by pushing the plunger of a syringe attached to the end of the PEG tube. The force of pushing the plunger on the syringe blew the side port of the PEG tube open. LPN #1 poured the diluted medication into the enteral syringe. An undetermined amount of medication leaked from the tube, resulting in Resident #16 not receiving the complete dose of medication. Interview with Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked if PEG tube placement should be checked before medication was administered. The DON stated, .yes . The DON confirmed that medication should be administered as ordered.",2020-09-01
511,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,761,D,0,1,U7IF11,"**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 stored when 1 of 6 (Licensed Practical Nurse (LPN) #1) nurses left medication unattended during medication administration. The findings include: 1. The facility's Storage of Medications policy revised (MONTH) 2007 documented, .store all drugs and biologicals in a safe, secure .manner . 2. Observations on 2/19/19 beginning at 2:38 PM, in the 300 hall, LPN #1 placed a [MEDICATION NAME] 200 milligram (mg) tablet in a cup on the medication cart. LPN #1 entered room [ROOM NUMBER] to wash her hands, leaving the medication on the cart unattended and out of sight. 3. Observations on 2/19/19 beginning at 3:26 PM, in Resident #47's room, LPN #1 placed a vial of [MEDICATION NAME] medication on Resident #47's table. LPN #1 left the room leaving the medication unattended and out of sight. Interview with the Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked should medication be left unattended. The DON stated, .No .",2020-09-01
512,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2018-04-04,759,D,0,1,GCV311,"**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 1 of 4 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 9 medication errors were observed out of 29 opportunities for error, resulting in a medication error rate of 31.03%. The findings included: The facility's Medications via Gastrostomy Tube policy documented, .Purpose .To administer medications through a gastrostomy tube in an accurate, safe, timely, and sanitary manner .Remove plug at the end of the tube and attach syringe .Clamp tube once correct placement is noted .Remove piston from syringe .pour up to 30 ml (milliliters) of water into syringe .Tilt the tube to allow air to escape as the fluid flows downward .Just before the syringe empties of water, add medication in accordance with physician order [REDACTED]. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg (milligrams) .BID (twice a day) . The physician's orders [REDACTED]. 1.DAILY-VIT (Multivitamin) TAB (tablet) GIVE ONE PER PEG (Percutaneous Endoscopic Gastrostomy) TUBE ONCE DAILY . 2.[MEDICATION NAME] (Atorvastatin) 10 MG (milligram) TABLET ONE TAB PER PEG TUBE DAILY . 3.MAGNESIUM OXIDE 400 MG TABLET GIVE ONE TAB PER PEG TUBE ONCE DAILY . 4.OS-CAL (Oyster Shell Calcium) 500 (MG) TABLET GIVE ONE PER PEG BID (twice daily) . 5.[MEDICATION NAME] POWDER (Polyethylene [MEDICATION NAME]) 17 GRAMS VIA PEG TUBE .DAILY . 6.[MEDICATION NAME] (LEVETIRACETAM) 100 MG/ML .GIVE 5ML BY MOUTH TWICE A DAY . 7.[MEDICATION NAME] ([MEDICATION NAME]) 15 MG TABLET GIVE ONE TAB PER PEG DAILY . 8.[MEDICATION NAME] .37.5 MG TABLET .ONE TABLET VIA (PEG) TUBE TWICE A DAY . Observations in Resident #21's room, on 4/3/18 beginning at 10:52 AM, revealed the following: 1. RN #1 donned gloves, exposed Resident #21's PEG tube, and placed a washcloth covered with 2 brown paper napkins under the peg tube. RN #1 obtained a 60 ml piston syringe and used the syringe to draw up the dissolved [MEDICATION NAME], connected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #1. 2. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, drew up the dissolved Multivitamin, connected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins, which resulted in medication error #2. 3. RN #1 flushed the peg tube with 10 mls of water, disconnected the syringe, drew up the dissolved Atorvastatin and administered the medication. RN #1 disconnected the syringe and an undetermined amount of fluid leaked out of the PEG tube onto the napkins which resulted in medication error #3. 4. RN #1 flushed the PEG tube with 10 mls of water, disconnected the syringe, drew up the dissolved Magnesium Oxide and administered the medication. RN #1 disconnected the syringe and an undetermined amount of fluid leaked out of the PEG tube onto the napkins which resulted in medication error #4. 5. RN #1 then flushed the PEG tube with 10 mls of water, drew up the dissolved Oyster Shell Calcium, reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins, which resulted in medication error #5. 6. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved Polyethylene [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #6. 7. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved Levetiracetam, reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #7. 8. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #8. 9. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #9. After all of the medications had been administered through the PEG tube, the napkins under the PEG tube were saturated with liquid and multicolored particles. RN #1's failure to properly clamp the PEG tube after each medication was administered resulted in Resident #1 not receiving the full dose of each medication as ordered, with a medication error rate of 31.03%. Interview with RN #1 on 4/3/18 at 11:15 AM in Resident #21's room, RN #1 confirmed that the 2 napkins she had placed under the PEG tube were completely saturated with liquid and had some particles on them. Interview with the Director of Nursing (DON) on 4/4/18 at 2:08 PM in the Family Room, The DON confirmed that there would be no way to know if Resident #21 received all the medication if fluid was flowing out of the PEG tube after each time a medication was administered.",2020-09-01
513,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2018-04-04,880,D,0,1,GCV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, document review, and interview, the facility failed to ensure employees were free of communicable disease for 1 of 8 (Certified Nursing Assistant (CNA) #1) newly hired employees reviewed. The findings included: The facility's (Named Facility) CLINICAL SUPPORT POLICY documented, .Each newly hired employee will be screened for TB ([MEDICAL CONDITION]) infection and disease after an employment offer has been made but prior to the employee's duty assignment . The facility was unable to provide documentation that CNA #1 was free of communicable disease. Review of facility documents revealed that CNA #1 actually worked 25 scheduled shifts from 2/12/18 to 3/31/18. Interview with the Administrator on 4/4/18 at 3:47 PM in the Family Room, the Administrator was asked if the facility had no medical proof that CNA #1 was free of communicable disease. The Administrator stated, Correct.",2020-09-01
517,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,641,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to complete a quarterly Minimum Data Set (MDS) for 1 of 35 (Resident #128) sampled residents reviewed. The findings include: 1. The facility's MDS Assessment policy revised 3/2019 documented, .All MDS assessments (e.g.,admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded .in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations governing the transmission of MDS data .Quarterly (Non-Comprehensive) . 2. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's medical record revealed Resident #128 had an admission MDS assessment on 3/21/19. A quarterly MDS assessment would have been due on 6/21/19. The facility failed to complete a quarterly assessment until 7/18/19. Interview with MDS Coordinator #1 on 7/18/19 at 10:56 AM, in the Conference Room, MDS Coordinator #1 was asked if Resident #128's quarterly assessment due 6/21/19 had been completed. MDS Coordinator #1 stated, .no it hasn't been done .it hasn't been started . Interview with the Administrator on 7/18/19 at 1:22 PM, in the Conference Room, the Administrator was asked if the quarterly assessment due 6/21/19 for Resident #128 should have been completed timely. The Administrator stated, Yes, it should have.",2020-09-01
518,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,656,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 31 (Resident #126) sampled residents reviewed. The findings include: 1. The facility's undated Care Planning Interdisciplinary Team policy documented, .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) (Minimum Data Set) . 2. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the admission MDS was completed 6/21/19. The comprehensive care plan should have been completed by 6/28/19. The facility was unable to provide a comprehensive care plan for Resident #126. 3. Interview with MDS Coordinator #2 on 7/18/19 at 6:06 PM, in the Conference Room, MDS Coordinator #2 was asked what overdue meant in the Point Click Care system )the facility's electronic medical record system). MDS Coordinator #2 stated, It (care plan) hasn't been completed. MDS Coordinator #2 was asked when the comprehensive care plan was due. MDS Coordinator #2 stated, .21 days after admission . MDS Coordinator #2 was asked whose responsibility it was to complete the comprehensive care plan. MDS Coordinator #2 stated, .the person who completed the assessment .",2020-09-01
519,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,689,D,0,1,DRI311,"Based on observation and interview, the facility failed to ensure the environment was free of accident hazards when unsecured chemicals were observed in 1 of 4 (100 Hall) shower rooms. The findings include: Observations in the 100 Hall shower room on 7/15/19 at 5:23 AM, 7:46 AM, 8:01 AM, and 8:14 AM, revealed (2) 1 gallon plastic containers of hair and body cleanser and (1) opened, unlabeled and unsealed plastic container, containing a clear yellowish liquid with a strong chemical odor. Interview with Certified Nursing Assistant (CNA) #1 on 7/15/19 at 9:14 AM, in the 100 Hall shower room, CNA #1 was asked if the hair and body cleanser should be left out when not in use. CNA #1 stated, .no. CNA #1 was asked what is this clear yellowish liquid in the unlabeled, unsealed and opened gallon container. CNA #1 stated, .it is bleach . CNA #1 was then asked if these items should be stored unsecured, unsealed and unlabeled in the shower room. CNA #1 stated, No, they should be locked up. Interview with the Administrator on 7/18/19 at 6:19 PM, in the Administrator Office, the Administrator was asked how should chemicals such as bleach be stored. The Administrator stated, .not accessible to residents . The Administrator was asked how should hair and body cleanser be stored in the shower room when not in use. The Administrator stated, .in a locked cabinet .",2020-09-01
520,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,698,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 1 of 1 (Resident #130) residents reviewed for [MEDICAL TREATMENT]. The findings include: 1. The facility's undated [MEDICAL TREATMENT] Policy and Procedure documented, .When resident is sent to [MEDICAL TREATMENT] unit .copy of the Facility [MEDICAL TREATMENT] Communication Record to accompany the resident .When the resident returns from [MEDICAL TREATMENT] unit .Review all test reports and the [MEDICAL TREATMENT] Communication Record returned with the resident . 2. Medical record review revealed Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 day admission Minimum Data Set ((MDS) dated [DATE] documented Resident #130 received [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication record revealed the following forms were not completed prior to [MEDICAL TREATMENT] on 6/12/19, 6/21/19, 6/24/19, 6/26/19, 6/28/19, 7/8/19, 7/12/19, and 7/15/19. Interview with the Director of Nursing (DON) on 7/18/19 at 10:38 AM, in the Conference Room, the DON was asked when should the [MEDICAL TREATMENT] communication records be completed. The DON stated, Before the resident leave the facility for [MEDICAL TREATMENT]. The DON was asked should the resident have their communication records completed for each [MEDICAL TREATMENT] visit. The DON stated, Yes.",2020-09-01
524,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,842,D,0,1,DRI311,"**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 weights were accurately obtained and recorded for 1of 4 (Resident #10) sampled residents reviewed for nutritional risk. The findings include: 1. The facility's undated Weight Monitoring policy documented, Monthly weights will be done by the C.N.A (Certified Nursing Assistant) .All weights will be documented in the weight record .Any resident with a weight of five-pound discrepancy will be reweighed by the charge nurse immediately .The charge nurse will be reweighing any discrepancy . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Weights and Vitals Summary record dated 7/17/19 revealed no recorded weights for (MONTH) 2019 and (MONTH) 2019. Review of the facility's Weights and Vitals Summary record revealed a weight discrepancy of 27.2 pounds from 4/24/19 (259.2 pounds) to 7/3/19 (232 pounds) and a weight discrepancy of 24.5 pounds from 7/3/19 (232 pounds) to 7/17/19 (256.5 pounds) with no recorded reweights. Observations at the end of the 200 Hall on 7/17/19 at 2:10 PM, revealed the weight of the wheelchair was obtained by the Assistant Director of Nursing (ADON) and resulted in a 39.1 pound weight. Certified Nursing Assistant (CNA) #1 and CNA #2 assisted Resident #10 onto the digital wheelchair scales while in his wheelchair and obtained the weight for Resident #10 with the result of 256.5 pounds without the deduction of the wheelchair weight. The weight entered into the electronic medical record for 7/17/19 was 256.5 and the wheelchair weight was not deducted from this weight. Interview with the Director of Nursing (DON) on 7/17/19 at 6:14 PM, in the Conference Room, the DON was asked if the weight of 256.5 pounds that was recorded in the computer for Resident #10 on 7/17/19 reflected the deduction of the wheelchair weight of 39.1 pounds. The DON stated, No, it was not .from admission until now the restorative aids have failed to subtract the wheelchair weight. The DON was asked who was responsible for ensuring that the weights are correct, and if there were any discrepancies that reweights were obtained. The DON stated, The ADON. Interview with the ADON on 7/18/19 at 4:28 PM, in the Conference Room, the ADON confirmed that it was his responsibility to put all weights into the computer system for review, all residents with weight discrepancies should be reweighed, and that the restorative staff failed to deduct the wheelchair weight for Resident #10.",2020-09-01
525,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,880,D,0,1,DRI311,"**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 practices to prevent the potential spread of infection were followed when 1 of 1 (Resident #126) residents reviewed in transmission based precautions did not have isolation signage on the resident's door and 1 of 1 (Licensed Practical Nurse (LPN) #8) nurses failed to perform proper hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube care. The findings include: 1. The facility's undated Handwashing Technique policy documented, .To prevent and control transmission of infections, employees hands will be washed . 2. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].contact isolation d/t (due to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) (a bacterium with antibiotic resistance) in sputum . Observations on the 100 Hall outside of Resident #126's room on 7/15/19 at 5:25 AM, 6:43 AM, and 8:32 AM, revealed no sign on the door alerting staff or visitors to see the nurse prior to entering the room. Interview with LPN #9 on 7/15/19 at 8:32 AM, on the 100 Hall, LPN #9 was asked if Resident #126 was in isolation. LPN #9 stated, Yes . Interview with the Director of Nursing (DON) on 7/18/19 at 5:50 PM, in the Conference Room, the DON was asked how staff, visitors, and residents were notified that someone was in isolation. The DON stated, .sign on the door that says please see nurse before entering. 3. Medical record review revealed Resident #303 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Clean peg site with soap and water, pat dry .apply TAO (triple antibiotic ointment) .apply gauze to peg site Q (every) shift . Observations in Resident #303's room on 7/18/19 at 8:53 AM, revealed LPN #8 washed her hands, donned gloves, prepared soapy water in an emesis basin, removed the old dressing from the enteral feeding site, cleansed around the enteral feeding site with soap and water, removed her gloves, and donned clean gloves without performing hand hygiene. LPN #8 dried the area around the enteral feeding site, removed her right glove, donned a glove on her right hand, without performing hand hygiene, applied a topical antibiotic ointment to the enteral feeding site and applied a split gauze sponge around the enteral feeding site. Interview with the DON on 7/18/19 at 9:18 AM, in the Conference Room, the DON was asked what she expected her staff to do between glove changes. The DON stated, Wash their hands.",2020-09-01
526,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,684,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to follow physician's treatment orders for 1 of 3 (Resident #3) sampled residents reviewed for wound care and treatment. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].Cleanse lt (left) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd (every day)/prn (as needed) one time a day for arterial/venous ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Review of physician's orders [REDACTED].Cleanse rt (right) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd/prn. one time a day for venous/arterial ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Observation in Resident #3's room on 7/16/18 at 3:00 PM revealed the dressings on Resident #3's bilateral lower extremities were dated 7/13/18. The dressings were not changed and treatments were not provided on 7/14/18 or 7/15/18 as ordered by the physician. Interview with Licensed Practical Nurse (LPN) #1 on 7/16/18 at 3:30 PM in Resident #3's room, LPN #1 confirmed Resident #3's bilateral lower extremities dressings were dated 7/13/18. The facility failed to ensure wound treatments were changed according to physician's orders [REDACTED].",2020-09-01
527,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,773,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to obtain laboratory (lab) tests as ordered and failed to promptly notify the physician of a critical laboratory result for 1 of 3 (Resident #9) sampled residents reviewed for laboratory services. The findings included: Review of the undated (Named Facility) Lab Protocol documented, .Lab results are pulled from (Named Lab Company) system daily Monday-Friday by designated personnel and reviewed by DON (Director of Nursing) and ADON (Assistant Director of Nursing) .All critical labs are to be called to facility per (Named Lab Company) Monday-Friday. Nurses are to accept critical lab reports and call MD (Medical Doctor) with results. Monday-Friday if labs are called after hours then 3-11 supervisor/charge nurses are to take critical lab results and report to MD/DNP (Doctorate Nurse Practitioner) . Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #9 was assessed with [REDACTED].#9 was severely cognitively impaired. Review of a physician order [REDACTED].[MEDICATION NAME] Suspension (generic [MEDICATION NAME]) 125 mg/5ml (125 milligrams in 5 milliliters) give 8 ml by mouth every 12 hours for anticonvulsant . Review of a physician order [REDACTED].[MEDICATION NAME] level every 3 months starting on 5/1/18 . The [MEDICATION NAME] level result dated 5/1/18 was low at 7.0 ug/ml (units per gram/milliliter) with a reference range of 10.0-20.0 ug/ml. The physician ordered a one time dose of [MEDICATION NAME] suspension 500 mg (milligram) to be given on 5/2/18. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level one time . There was no documentation this repeat [MEDICATION NAME] level was obtained as ordered. Review of a physician order [REDACTED]. This [MEDICATION NAME] level result was at a critical level high of 25.4 ug/ml. The physician was notified and gave an order to hold the [MEDICATION NAME] Suspension until 5/25/18 and to repeat the [MEDICATION NAME] level on 5/24/18. There was no documentation this repeat [MEDICATION NAME] level was performed. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level on 5/24/18 . There was no documentation that this repeat level was obtained. The physician visited the resident on 5/25/18 and ordered a STAT( immediate) [MEDICATION NAME] level to be drawn. This STAT [MEDICATION NAME] level result was high at 23.5 ug/ml. The physician decreased the [MEDICATION NAME] suspension dosage to 7 ml two times a day and ordered a repeat [MEDICATION NAME] level to be drawn in one week. There was no documentation this repeat [MEDICATION NAME] level was performed as ordered. A Nurses note dated 5/31/18 revealed the physician was notified again of the high [MEDICATION NAME] level result dated 5/25/18 with an order obtained to further decrease the [MEDICATION NAME] Suspension dose to 6 ml twice a day and to repeat a [MEDICATION NAME] level on 6/7/18. The 6/7/18 [MEDICATION NAME] level result was a critical high level of greater than 34. The laboratory result form documented the critical high level was called to (Named Licensed Practical Nurse) on 6/8/18 at 7:49 AM. There was no documentation the physician was notified of this critical high result until 6/9/18. The physician discontinued the [MEDICATION NAME] dose until 6/12/18 and ordered a recheck of the [MEDICATION NAME] level to be drawn on 6/11/18. The 6/11/18 level result was within normal limits of 12.7 ug/ml. The physician restarted the [MEDICATION NAME] suspension dosage at 5 ml two times a day on 6/12/18. Observations of Resident #9 on 7/18/18 at 10:30 AM revealed him to be alert, up in a geri chair at bedside watching television and voiced no complaints. Interview with the Unit Manager on 7/18/18 at 7:50 AM, in the Conference room, the Unit Manager was asked about the missed labs and delay in physician notification of the critical lab result and the Unit Manager stated, I am not sure what happened about the 5/2/18 lab order, I do know the 5/24/18 lab order was canceled by the laboratory and was not sure why was not aware of the redraw order for the first of (MONTH) .I saw that critical lab (on 6/9/18) for 6/7/18 and had the LPN handle that on 6/9/18. Not sure why the nurse did not inform the physician of that critical lab. The resident never displayed any symptoms of toxicity. Interview with the Nurse Practitioner on 7/18/18 at 10:00 AM, in the Conference room, the Nurse Practitioner (NP) involved in Resident #9's care was asked about the missed labs and delay in notification of the critical high [MEDICATION NAME] level and the NP stated, I was not aware the levels were not drawn on the first of June, (Named Resident #9) had no signs/symptoms during that time, I decreased his [MEDICATION NAME] slowly .I do expect to be notified of critical lab results. The facility failed to ensure that laboratory tests were obtained as ordered and failed to ensure prompt notification of a critical [MEDICATION NAME] level on Resident #9.",2020-09-01
528,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,806,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on menu review, tray card review, medical record review, observations and interviews, the facility failed to ensure nourishing, palatable meals, honoring resident preferences were served to 1 of 3 (Resident #1) sampled residents reviewed for nutrition. The findings included: Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed Resident #1 with an order dated 6/15/18 for a Mechanical Soft Diet. Resident #1 was assessed on the 1/26/18 Annual and the 4/25/18 Quarterly Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #1 was independent with decision making skills and required extensive assistance with Activities of Daily Living (ADLs). Further medical record review revealed the only Dietary Progress note to date in (YEAR) was dated 6/14/18 and documented Resident #1 had a 3% (percent) weight loss that month and a recommendation to liberalize her diet was noted. A Nurse's note dated 6/19/18 documented, Patient complaint of meal not being what she wants .she wants to talk to dietary supervisor . There was no documentation in the medical record the Dietary Manager or the Registered Dietician had conducted a follow up visit to address the 6/19/18 request made by the resident. There were no dietary notes in the medical record documenting the frequent trips to the grocery or attempts to accommodate Resident #1's food preferences. The Care Plan did not address Resident #1's food complaints/preferences/attempts to accommodate. Review of the Noon meal Menu for 7/15/18 revealed Roast Beef, Mashed Potatoes, Capri Mix Vegetables, Banana Cream Pie, and Dinner Roll to be served. The Noon meal Menu for 7/16/18 revealed Baked Chicken, Greens, Cornbread, and Strawberries with topping to be served. Observations on 7/15/18 at 12:20 PM of the noon meal revealed Resident #1 served Roast Beef, Vegetable Medley, and a Baked Sweet Potato. The Roast Beef and Sweet Potato were listed on the tray card as dislikes. The resident was observed to be eating the Sweet Potato and stated, .had one last night, get them frequently, have to eat something . Observations on 7/16/18 at 12:50 PM of the noon meal revealed Resident #1 served Baked Chicken, Greens, and a Baked Sweet Potato. The Sweet Potato was listed on the tray card as a dislike. The resident was observed to be eating the Sweet Potato and stated, .3 days in a row for Sweet Potatoes . Review of the tray card used in dietary to plate each meal for Resident #1 revealed the following foods listed as dislikes: No milk, juice, bread, chicken and dumplings, yams, roast beef, gravy or pork. Interview with the Dietary Manager on 7/11/18 at 10:30 AM, in the Conference room, the Dietary Manager stated, .(Named Resident #1) has given me a long list of dislikes on her tray cards .she is very picky, complains a lot about the food .we make frequent trips to the grocery for her meals . Interview with Resident #1 on 7/11/18 at 12 Noon, in the resident room, Resident #1 stated, .I have given the dietary manager a list of my likes and dislikes but they can't get that right . Interview with the Dietary Manager on 7/15/18 at 12:05 PM, in the Conference room, the Dietary Manager was asked to provide evidence such as notes and receipts of foods purchased to address the complaints/preferences of Resident #1 and stated, I don't have any receipts where I've bought food for her . Interview with the Director of Nursing (DON) on 7/18/18 at 11:15 AM, the DON was asked who completed the care plans related to dietary/food issues and stated, .Dietary would put those on the care plan. The DON was asked the care plan expectations regarding Resident #1's frequent food complaints and stated, I would expect all her dietary complaints, preferences and all that has been done to address them to be on the care plan. The facility failed to provide evidence the food complaints/preferences of Resident #1 were addressed, failed to ensure that food preferences were honored for Resident #1, and failed to ensure a variety of foods were served to Resident #1.",2020-09-01
529,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,157,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician of a significant change in status for 1 of 17 (Resident #24) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].HumaLOG Solution .Inject as per sliding scale .For blood glucose .300-349 = (equal) 20 (units); 350 + (plus) (=) 24 If BS (Blood Sugar) over 349 give 24 units and call physician, subcutaneously before meals . A physician's orders [REDACTED].inject as per sliding scale .300-349 = 20 units, 350-600 = 24units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus) . Review of the Medication Administration Records (MARs) for 7/8/17 through 7/15/17 revealed the following blood sugar levels greater than 349: 7/8/17 at 9:00 PM = 376 7/11/17 at 4:00 PM = 450 7/13/17 at 9:00 PM = 571 7/15/17 at 5:00 AM = 454 The facility was unable to provide any documentation that the physician or nurse practitioner was notified regarding the elevated blood sugar levels on 7/8/17, 7/11/17, 7/13/17, and 7/15/17. Interview with the Director of Nursing (DON) on 8/24/17 at 9:55 AM, in the restorative dining room, the DON was asked what the protocol was for elevated blood sugar levels. The DON stated, Follow physician's orders [REDACTED]. The DON was asked if the nurses should document that the physician was notified. The DON stated Yes .in the progress notes . The DON was unable to find any documentation that the physician had been notified for the elevated blood sugar levels. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 11:37 AM, in the conference room, the DNP was asked when she expected to be notified regarding elevated blood sugar levels. The DNP stated, .there are standing orders that they are supposed to call me if their blood sugar is greater than 350 . The DNP was asked if she could remember being notified by the nursing staff that Resident #24's blood sugar was greater than 350. The DNP stated, At home? No .",2020-09-01
530,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,282,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow care plan interventions for medications and nutritional supplements for 3 of 17 (Resident #51, 55 and 100) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The signed physician's orders [REDACTED].Laboratory .[MEDICATION NAME] (blood level) . q (every) 6 months November/May . Medical record review revealed no documentation that Resident #51's [MEDICATION NAME] level had been checked since 5/2/16. The care plan dated 8/11/17 documented, .Obtain and monitor lab/diagnostic work as ordered . Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 12:02 PM, in the conference room, the DNP was asked if she expected her orders to be followed. The DNP stated, I expect them to be done . Interview with the Director of Nursing (DON) on 8/23/17 at 11:21 AM, in the conference room, the DON was asked if she expected staff to follow the care plan. The DON stated, Yes. 2. Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Oxalate Tablet 10mg (milligram) Give 1 tablet by mouth one time a day for Depression . The care plan dated 8/3/17 documented, .uses antidepressant .r/t (related to) Depression .Monitor/document side effects and effectiveness . The facility was unable to provide any documentation that Resident #55 was monitored for medication side effects or effectiveness. Interview with the DON on 8/24/17 at 2:37 PM, in the conference room, the DON was asked if the staff should have been monitoring and documenting for side effects for antidepressant use. The DON stated, Yes. The DON was asked if the care plan had been followed for Resident #55. The DON stated, No. 3. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for nutrition dated 8/3/17 included the intervention to provide supplements as ordered. The physician's orders [REDACTED].Med Pass (a nutritional supplement) four times a day for Weight Loss Give 8 oz (ounces) .4 x (times) a day . Review of the Medication Administration Record [REDACTED]. Interview with the DON on 8/23/17 at 10:06 AM, in the conference room, the DON was shown Resident #100's MARs and was asked what does the empty blank mean. The DON stated, .not documented. The DON was asked did Resident #100 receive the Med Pass as ordered. The DON stated, .not documented, not done . Interview with the DON on 8/23/17 at 11:21 AM, in the conference room, the DON was shown Resident #100's care plan and was asked if Resident #100 had received all of her supplements as ordered (med pass) would her care plan have been followed. The DON stated, No. The DON was asked if that was acceptable. The DON stated, No.",2020-09-01
531,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,309,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders related to diabetic care for 1 of 17 (Resident #24) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 was severely cognitively impaired, had [DIAGNOSES REDACTED]. A physician's order dated 7/5/17 documented, Insulin NPH (Human) ([MEDICATION NAME]) Suspension Pen injector 100 UNIT/ ML (units per milliliter) Inject 50 units subcutaneously two times a day for DM (Diabetes Mellitus) . A physician's order dated 7/8/17 documented, .HumaLOG Solution .Inject as per sliding scale .For blood glucose .300-349 = (equal) 20 (units); 350 + (plus)=24 If BS (Blood Sugar) over 349 give 24 units and call physician, subcutaneously before meals . A physician's order dated 7/14/17 documented, HumaLOG Solution .inject as per sliding scale .300-349 = 20 units, 350-600 = 24units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM . Review of the Medication Administration Records (MARs) for 7/5/17 through 7/15/17 revealed the following: a. Blood Sugar Levels greater than 349 with no physician notification documented: 7/8/17 at 9:00 PM = 376 7/11/17 at 4:00 PM = 450 7/13/17 at 9:00 PM = 571 7/15/17 at 5:00 AM = 454 The facility was unable to provide any documentation that the physician or nurse practitioner was notified regarding the elevated blood sugar levels on 7/8/17, 7/11/17, 7/13/17, and 7/15/17. b. There was no documentation that Resident #24 received his 50 units of NPH insulin as scheduled on 7/14/17 at 8:00 AM. c. There was no documentation that Resident #24's blood sugar was checked on 7/14/17 at 11:00 AM and 4:00 PM as ordered. Interview with the Director of Nursing (DON) on 8/24/17 at 9:55 AM, in the restorative dining room, the DON was asked what the protocol was for elevated blood sugar levels. The DON stated, Follow physician's orders .I believe if it's (the blood sugar level) is over 400 notify the physician . The DON was asked if the nurses should document that the physician was notified. The DON stated Yes .in the progress notes . The DON was unable to find any documentation that the physician had been notified for the elevated blood sugar levels. The DON confirmed there was no documentation that Resident #24 received his scheduled morning dose of NPH insulin at 8:00AM, 11:00 AM, or 4:00 PM and Resident #24 did not receive any of the scheduled blood sugar checks on 7/14/17. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 11:37 AM, in the conference room, the DNP was asked when she expected to be notified regarding elevated blood sugar levels. The DNP stated, .there are standing orders that they are supposed to call me if their blood sugar is greater than 350 . The DNP was asked if she could remember being notified by the nursing staff that Resident #24's blood sugar was greater than 350. The DNP stated, At home, No .",2020-09-01
532,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,312,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided for 1 of 4 (Resident #37) sampled residents reviewed of the 35 included in the stage 2 review. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #37 was moderately impaired cognitively, had no behaviors, did not refuse care, and required limited staff assistance with 1 person physical assist for dressing and personal hygiene, and was totally dependent on staff for bathing. Observation in the lobby on 8/21/17 at 1:42 PM, revealed Resident #37 seated in a wheelchair, dressed in a pair of dirty, unhemmed pants, a dirty sweatshirt, with a collared shirt underneath. The white-colored collar was gray and dirty. Observation in the lobby on 8/22/17 at 4:26 PM, revealed Resident #37 seated in a wheelchair dressed in the same dirty clothing he had on the day before. Interview with Licensed Practical Nurse (LPN) #2 on 8/22/17 at 5:45 PM, at the 200 hall nurses' station, LPN #2 was asked whether it was acceptable for a resident to wear the same dirty clothing 2 days in a row. LPN #2 stated, No. LPN #2 was asked how often Resident #37 was bathed. LPN #2 reviewed the shower schedule and confirmed Resident #37 should have been showered on the night shift last night. At 5:50 PM, in Resident #37's room, LPN #2 confirmed Resident #37 was wearing dirty clothing. LPN #2 was asked if that was acceptable. LPN #2 stated, No. Interview with the Director of Nursing (DON) on 8/24/17 at 8:15 AM, in the conference room, the DON was asked whether it was acceptable for a resident to be dressed in the same dirty clothing 2 days in a row. The DON stated, No, it is not acceptable .",2020-09-01
533,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,315,D,0,1,5LE311,"**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 appropriate care and services related to indwelling urinary catheters were provided for 1 of 1 (Resident #138) sampled residents reviewed with indwelling urinary catheters. The findings included: The facility's Foley Catheter Policy documented, .Do not leave the bag laying on the floor . Medical record review revealed Resident #138 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 2, which indicated Resident #138 was severely impaired cognitively, required extensive to total staff assistance for all activities of daily living, and had an indwelling urinary catheter. The care plan dated 6/9/17 documented, .Indwelling Catheter due to Pressure Ulcer Stage IV (4), sacrum . Observations in Resident #138's room on 8/21/17 at 2:47 PM and 5:51 PM, revealed the indwelling catheter tubing and bag were touching the floor. Observations in Resident #138's room on 8/22/17 at 4:16 PM, 8/23/17 at 8:22 AM and 10:41 AM, revealed the indwelling catheter tubing was touching the floor. Interview with Licensed Practical Nurse (LPN) #3 on 8/22/17 at 4:27 PM, in Resident #138's room, LPN #3 was asked whether it was acceptable for the indwelling catheter bag or tubing to be touching the floor. LPN #3 stated, It's not supposed to be .They do that sometimes . Interview with Registered Nurse (RN) #1 on 8/23/17 at 11:00 AM, in Resident #138's room, RN #1 was asked whether the indwelling catheter bag should be touching the floor. RN #1 did not answer. RN #1 picked up the indwelling catheter bag, placed it back on the floor, walked to the other side of the bed, raised the bed, walked back around the bed, picked up the catheter bag and hung it on the side of the bed with the catheter bag still touching the floor. Interview with the Director of Nursing (DON) on 8/24/17 at 8:15 AM, in the conference room, the DON was asked whether it was acceptable for an indwelling urinary catheter bag or catheter tubing to be touching the floor. The DON stated, No.",2020-09-01
534,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,322,D,0,1,5LE311,"**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 1 of 1 (Resident #4) sampled residents with a Percutaneous Endoscopic Gastrostomy (PEG) tube received enteral feeding according to physician's orders [REDACTED].#2) nurses observed during medication administration failed to administer medications through a PEG tube according to the facility policy. The findings included: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Enteral Feed Order every shift Glucerna 1.5 @ (at) 80ml/hr (milliliters per hour) x (times) 20 hours . Observations in Resident #4's room on 8/21/17 at 9:52 AM, 1:03 PM, and on 8/22/17 at 9:05 PM, revealed Resident #4 was in his room with no enteral nutrition infusing. On 8/22/17 PM at 1:18 PM and 2:00 PM, revealed Resident #4 was resting in his bed with Glucerna 1.5 Cal infusing per pump at 70 ml/hr. Interview with the Director of Nursing (DON) on 8/22/17 at 2:12 PM, in Resident #4's room regarding the infusion rate of the feeding, the DON confirmed the tube feeding was infusing at 70 ml/hr instead of the ordered 80 cc per hour. Interview with the DON on 8/24/17 at 8:30 PM, in the conference room, the DON was asked how she expected the nurses to ensure the correct rate for the enteral nutrition was infusing. The DON stated, Check the order, and check the rate . 2. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES: ENTERAL TUBE MEDICATION ADMINISTRATION policy documented, .3) Crush tablets and dissolve in 30 ml (milliliters) of warm water or other appropriate liquid. 4) Empty capsule contents into 30 ml of warm water or other appropriate liquid. 5) Dilute liquid medications with 10-30 ml of warm water or enteral formula .Administer liquid medications first . Observations in Resident #4's room on 8/24/17 at 9:10 AM, revealed LPN #2 crushed Aspirin 81 mg (milligrams) 1 tablet, and Multiple Vitamin 1 tablet, emptied 2 [MEDICATION NAME] Sprinkles capsules, and placed each medication in a separate medicine cup. LPN #2 then poured Levetiracetam 100 mg/ml 15 ml in a medicine cup, carried the medications into the room and placed them on the over bed table. LPN #2 attempted to flush the PEG tube with 30 ml of water and discovered it clogged. LPN #2 used the plunger of the syringe to clear the tube. LPN #2 then poured a dry medication into the 60 ml syringe followed by 5 ml water, placed the next dry medication into the syringe and followed it with 5 ml of water, placed the 3rd dry medication into the syringe and followed if with 5 ml of water. LPN #2 then poured the 15 ml of undiluted Levetiracetam into the syringe and flushed with 30 ml water. LPN #2 failed to dissolve the dry medications with water, failed to dilute the liquid medication prior to administering them and failed to administer the liquid medication first. Interview with the DON on 8/24/17 at 3:40 PM, in the conference room, the DON was asked when administering PEG medications should they put dry powder into the PEG tube. The DON stated, No. The DON was asked should liquid medications be administered without diluting. The DON stated, No.",2020-09-01
537,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,329,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders for anticonvulsant medication use and failed to monitor for [MEDICAL CONDITION] medication side effects for 2 of 5 (Resident #51 and 55) sampled residents reviewed for unnecessary medication use. The findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The signed physician's orders for (MONTH) (YEAR) with a start date of 4/24/14 documented, .Laboratory .[MEDICATION NAME] (blood level) . q (every) 6 months November/May . Medical record review revealed no documentation that Resident #51's [MEDICATION NAME] level had been checked since 5/2/16. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 12:02 PM, in the conference room, the DNP was asked if she expected her orders to be followed. The DNP stated, I expect them to be done . 2. Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders for (MONTH) (YEAR) documented, .[MEDICATION NAME] Oxalate Tablet 10mg (milligram) Give 1 tablet by mouth one time a day for Depression . The care plan dated 8/3/17 documented, .uses antidepressant .r/t (related to) Depression .Monitor/document side effects and effectiveness . The facility was unable to provide any documentation that Resident #55 was monitored for medication side effects or effectiveness. Interview with the Director of Nursing (DON) on 8/24/17 at 2:37 PM, in the conference room, the DON was asked if the staff should have been monitoring and documenting for side effects for antidepressant use. The DON stated, Yes.",2020-09-01
538,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,361,D,0,1,5LE311,"Based on review of job descriptions, personnel file review, observation, and interview, the facility failed to ensure the availability of qualified nutritional services as evidenced by 1 of 1 Certified Dietary Manager (DM) personnel files reviewed and 1 of 1 Registered Dietician (RD) personnel files reviewed to oversee the daily functioning and maintenance of the kitchen/dietary department or resident nutritional services. The findings included: The Registered Dietician Job Description documented, .Responsibilities include .Complete nutritional initial, quarterly, annual and significant change reviews on residents .Monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards . The Dietary Manager Job Description documented, .Responsible for daily operations of food service department .Specify standards and procedures for preparing food .Assure safe receiving, storage, preparation, and service of food .Prepare cleaning schedules and maintain equipment to ensure food safety .Ensure proper sanitation and safety practices of staff .Determine client diet needs and develop appropriate dietary plans in cooperation with RD and in compliance with physicians' orders . RD #1's personnel file documented the last day of employment was 5/10/17. RD #2's personnel file documented a hire date of 6/16/17. The DM's personnel file documented a hire date of 3/24/14 as Assistant DM, and a promotion to the position of DM on 11/27/16. The facility was unable to provide documentation the DM was either certified or currently enrolled in a certification program. Interview with the current uncertified DM on 8/24/17 at 9:22 AM, in the conference room, the DM was asked who he directed his questions related to nutrition or the kitchen during the period of time between 5/10/17 and 6/16/17. The DM stated, Really I didn't have anyone to talk to. I just took care of it the best I could. The facility was unable to provide documentation that a certified DM or an RD was available for consultation from 5/10/17 until 6/16/17. Refer to F325 and F371.",2020-09-01
540,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,372,D,0,1,5LE311,"Based on observation and interview, the facility failed to ensure sanitary garbage and refuse disposal on 1 of 4 (8/22/17) days of observation of the dumpster area. The findings included: Observations of the dumpster area on 8/22/17 at 4:00 PM and 6:15 PM, revealed paper trash on the ground surrounding the dumpsters, an open sliding door on one of the dumpsters, 10 large cardboard boxes stacked around the dumpsters, and a 55 gallon, uncovered trash container beside the dumpster full of trash with a foul odor. Interview with the Dietary Manager (DM) on 8/22/17 at 4:02 PM, at the dumpster area, the DM was asked whether the dumpster area was acceptable. The DM stated, No.",2020-09-01
542,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,441,D,0,1,5LE311,"Based on policy review, observation, and interview, the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #1 and 4) nurses observed during medication administration followed proper infection control practices to prevent the potential spread of infection. The findings included: 1. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES .EYE DROP ADMINISTRATION policy documented, .Remove the cap, taking care to avoid touching the dropper tip. Place the cap on an (a) clean, dry surface . 2. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES .ENTERAL TUBE MEDICATION ADMINISTRATION policy documented, Clean feeding syringe and return to bedside stand. Observations in Resident #83's room on 8/23/17 at 8:11 AM, revealed LPN #4 removed the cap from the eye drops and laid it on the nightstand without a clean barrier. Observations in Resident #71's room on 8/24/17 at 8:21 AM, revealed LPN #4 took the stethoscope from around her neck and used on the resident, put the stethoscope back around her neck without cleaning the stethoscope before or after using. LPN #4 failed to rinse the syringe plunger after administering medications via a Percutaneous Endoscopic Gastrostomy (PEG) tube. 3. Observations in Resident #4's room on 8/24/17 at 9:16 AM, revealed LPN #1 entered the room for PEG medication administration with a stethoscope around her neck, placed the stethoscope on the bed, picked the stethoscope back up, and, while attempting to position the stethoscope in her ears, placed one ear tube of the stethoscope on her mouth. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 8/24/17 at 3:40 PM, in the conference room, the DON was asked what she expected staff to do when administering eye drops. The DON stated, .put the lid on a barrier . The DON was asked what her expectations were for cleaning the stethoscope during PEG medication administration. The DON stated, Prior to checking for placement wipe with alcohol pad and when finished wipe off the stethoscope with alcohol pad.",2020-09-01
543,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,584,D,0,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to provide effective housekeeping services to maintain a sanitary, orderly, and comfortable environment by disrepair, trash and debris in resident rooms, strong urine odors and dirty toilets in resident bathrooms, and leaking air conditioners in 14 of 111 (room [ROOM NUMBER], 303, 304, 305, 309, 311, 312, 313, 315, 320, 325, 327, 331, and 332) rooms. The findings included: 1. The facility's OSHA (Occupational Safety and Health Administration) Environmental Rules and State Regulations policy documented, .35. Dust all vents .39. Be proactive with all odors . The facility's Cleaning and Disinfection of Environmental Surfaces policy (undated) documented, .Housekeeping surfaces (e.g. (example), floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visably soiled . 2. Observations in resident rooms during initial tour on 9/10/18 beginning at 9:40 AM, on 9/11/18 beginning at 8:25 AM, and on 9/12/18 beginning at 7:15 AM, revealed the following: a. room [ROOM NUMBER]: Large amount of unknown liquid spilled on the floor at the foot of the A bed and the B bed the top layer of the over-bed table flaking off b. room [ROOM NUMBER]: Wet, stained blanket on the floor under the air conditioner unit, a 60 cc (cubic centimeter) syringe under the A bed. Trash and debris on the floor around the A and B beds. Two 60 cc syringes on the floor by the B bed. The bathroom threshold was missing. An unknown brown substance at the entrance to the resident's room and bathroom. Clothes, an opened package of disposable briefs, shoes (men's) were stacked in the floor of the B bed's closet. The bottom drawer on B bed side dresser laying on the floor by the dresser c. room [ROOM NUMBER]: A wet, stained blanket under the air conditioner. A wet gown in the floor of the A bed's closet with gnats d. room [ROOM NUMBER]: Yellow/orange build up around the base of the toilet with a strong urine odor e. room [ROOM NUMBER]: Clothes, linens, and an open package of disposable brief in the floor in bed B's closet f. room [ROOM NUMBER]: Sink in the bathroom was covered with a plastic bag because it was leaking g. room [ROOM NUMBER]: Toilet with yellow/orange rings in the toilet bowl and stains on the seat h. room [ROOM NUMBER]: Dirty toilet i. room [ROOM NUMBER]: A wet brief and paper in the bathroom floor j. room [ROOM NUMBER]: Strong urine odor in bathroom k. room [ROOM NUMBER]: Large amount of unknown fluid in floor by the air conditioner l. room [ROOM NUMBER]: Strong urine odor m. room [ROOM NUMBER]:[NAME]robe door leaning against the wall in the bathroom n. room [ROOM NUMBER]: Strong urine odor in the bathroom. 3. Interview with the Director of Nursing (DON) on 9/12/18 at 7:15 AM, on the 300 hall, the DON stated .I need to get a team to come up and clean these rooms and maintenance to fix these leaks .room [ROOM NUMBER]'s floor has to be cleaned up .room [ROOM NUMBER]'s bathroom smells of urine and has to be cleaned .clothes and diapers should not be in the floor .room [ROOM NUMBER] .same thing . The surveyor pointed at the sink in room [ROOM NUMBER]'s bathroom and asked the DON why the plastic bag was on the sink. The DON stated, .I've had enough .I trust you .I don't need to see the rest of the rooms .I've never seen this hall this bad . Interview with Director of Maintenance (DOM) on 9/13/18 at 11:30 AM, in the conference room, the DOM was asked how maintenance is aware of issues that need to be fixed in the facility. The DOM stated, .have been in this position less than 3 weeks. Staff is supposed to be putting issues down in a log at each nursing station but sometimes they will stop one of us in the hall and it doesn't end up getting put in the log. The maintenance team now turns in a list of what they have taken care of each day and before I leave for the day, I make rounds to make sure they have done it right. I have talked with the Administrator and DON about having staff document issues in the log books .",2020-09-01
544,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,684,D,1,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow physician's orders for medication administration for 2 of 3 (Resident #102 and 108) residents reviewed for administration of medications and failed to follow physician's orders for treatment for 1 of 6 (Resident #108) residents reviewed for wound care and treatment. The findings include: 1. The facility's MEDICATION ADMINISTRATING - GENERAL GUIDELINES policy documented, .Medications are administered as prescribed . 2. Closed medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 3/23/18 documented, . 3/23/18 Arterial Ulcer to L (left) and R (right) lower legs .Surgical incision to the chest .Resident keeps pulling dressing off to bilateral legs and mid chest causing areas to reopen after healing .8/3/18 Resident rubbing right foot against sheets, causing blister (even after being redirected and educated by wound nurse) .non compliant with keeping heel Protectors on feet, and removing dressing from right foot . A physician's order dated 8/15/18 documented, .[MEDICATION NAME] Capsule 100 mg (milligram) .Give 1 capsule by mouth two times a day for anti-infective for 7 Days . Review of the medication administration record (MAR) dated 8/1/18 - 8/31/18 revealed the [MEDICATION NAME] was only documented as given on 8/15/18 and 8/22/18. Interview with the Director of Nursing (DON) on 9/25/18 at 3:30 PM in the Medical Director's Office, the DON confirmed the lack of documentation on the MAR and when asked why the [MEDICATION NAME] was not administered as ordered, the DON stated, .That I can not explain . 3. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 6/30/16 reviewed quarterly and updated as needed documented, .(Named Resident #108) has Chronic [MEDICAL CONDITION] of the BLE (bilateral lower extremity) placing her at risk for repeated infections .9/30/18 [MEDICATION NAME] (anti-infective) BID (twice daily) x (times) 14 days for infection .Perform wound care as per order . The plan of care addressing inappropriate behaviors dated 3/31/17 documented, .(Named Resident #108) has a behavior of refusing care/refusing to take a shower .10/2/17 Not consistently allowing staff to change her - saturated briefs or dressings - leading to possibility of infections . a. The physician's order dated 9/16/18 documented, .[MEDICATION NAME] Tablet 500 - 125 MG .Give 1 tablet by mouth two times a day for Infection .x 14 days .Order Date .09/16/2018 .Start Date .09/30/2018 . Review of the MAR dated 9/1/18 - 9/30/18 revealed the [MEDICATION NAME] had not been documented as given. Interview with LPN #3, on 9/19/18 at 10:45 AM in the Administrator's Office, LPN #3 stated on 9/16/18 she had received a telephone order from the physician to begin [MEDICATION NAME] 500-125 mg twice daily for 14 days [MEDICATION NAME] (a preventive measure). LPN #3 continued the interview and revealed she had given the order to Resident #108's nurse, Registered Nurse (RN) #2 to enter into the electronic ordering system. Observation and interview with LPN #4 on 9/25/18 at 11:45 AM at the 300 hall nurses station, LPN #4 was asked if Resident #108 was receiving [MEDICATION NAME]. LPN #4 revealed the medication was in the resident's medication drawer and stated she had administered one that morning. LPN #4 opened the drawer which contained a prescription box of 26 [MEDICATION NAME] tablets. LPN #4 counted the tablets and there were 18 tablets left to count. Eight tablets of the prescription had been administered. The resident should have received 18 tablets by 9/25/18. LPN #4 checked the resident's electronic MAR to verify she had given the medication and then stated according to the MAR, the [MEDICATION NAME] could not be documented as given until 9/30/18. LPN #4 then stated, .I guess I didn't (give the medication) . The order was entered into the electronic physician's ordering system incorrectly with a start date of 9/30/18 instead of 9/16/18. Interview with the DON on 9/25/18 at 1:07 PM in the DON Office, the DON was asked if Resident #108's [MEDICATION NAME] had not been administered. The DON stated, .It was ordered [MEDICATION NAME] . When asked, if ordered [MEDICATION NAME] or not, should the medication have been given, the DON stated, Yes. Interview with LPN #3 on 9/25/18 at 2:05 PM in the Medical Director's Office, LPN #3 stated RN #2 had entered Resident #108's [MEDICATION NAME] order into the electronic ordering system incorrectly and the resident should have been receiving the medication twice daily starting 9/16/18. b. Review of the physician's wound treatment orders dated 8/9/18 revealed Resident #108's right and left lower leg arterial/venous ulcers were to be cleansed with wound cleanser, patted dry, Mafenide (a prescription anti-infective) applied to the wound bed, a barrier cream applied to the skin surrounding the wounds, covered with collagen dressings (promotes healthy tissue growth) and wrapped with Kerlix (gauze) daily. Review of the MAR dated 9/1/18-9/30/18 revealed Resident #108's wound treatments had not been documented as administered on 9/15/18. Observations in Resident #108's room on 9/20/18 at 2:00 PM revealed the treatment nurse, Licensed Practical Nurse (LPN) #3 performing wound care for the resident. The resident's right lower extremity had a large irregularly shaped open wound on the back and sides of the leg from inner ankle area to the upper calf/shin area with the tendon exposed at the back of the leg between the ankle and mid-calf. The wound measurements were: Length: 28.4 centimeters (cm) x (by) Width 18.5 cm x Depth 0.1 cm. There were scattered areas of necrotic tissue noted. However, approximately 95 percent of the wound was pink/granulation tissue. There was little drainage and no foul odor noted. The left lower extremity had 3 smaller scattered wounds with pink healthy tissue exposed, the largest of which measured: Length 1.8 cm x Width 1.8 cm x Depth 0.1 cm. There was little drainage and no foul odor was noted. Deficient practice was not observed during wound care. Interview with RN #2 on 9/19/18 at 10:45 AM in the Administrator's Office, RN #2 revealed she had been Resident #108's nurse on 9/15/18 and had not completed her wound care as ordered. Telephone interview with RN #3 on 9/20/18 at 11:23 AM, RN #3 was asked if she had completed the wound treatments for Resident #108. RN #3 revealed she had not. Continuing the interview RN #3 revealed she had worked as the Facility House Supervisor on 9/15/18. When asked if she was responsible for performing wound treatments as House Supervisor, RN #3 stated the nurses were responsible for treatments.",2020-09-01
545,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,689,D,0,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the resident's environment remained free from accident hazards when pools of water were observed in 3 of 111 (room [ROOM NUMBER],325, and 421) resident rooms, and 1 of 2 (100 hall) janitor closets was observed unlocked. The findings included: 1. The facility's OSHA (Occupational Safety and Health Administration) Environmental Rules and State Regulations policy documented, .3. Keep all chemicals locked away or on your person at all times .5. Check to make sure a door is locked at all times before leaving .janitor closet doors must be closed and locked AT ALL TIMES . 2. Observations on 9/10/18 beginning at 9:40 AM revealed the following: a. room [ROOM NUMBER]: A large amount of unknown liquid on the floor at the foot of the A bed and the B bed b. room [ROOM NUMBER]: A large amount of unknown fluid in floor by the air conditioner Observations in room [ROOM NUMBER] on 9/11/18 at 11:34 AM, and 3:10 PM, revealed a large amount of water on the floor and along the wall, under the dresser across from Bed A and B beds, and in the middle of the room. Both of the residents were in their beds. There was no signage warning of the wet floor. Interview with Certified Nursing Assistant (CNA) #1 on 9/11/18 at 3:22 PM, in the 400 hallway outside of room [ROOM NUMBER], CNA #1 was asked how long there had been a problem with the water leak in room [ROOM NUMBER]. CNA #1 stated, Off and on for about a month . Interview with the Director of Nursing (DON) on 9/12/18 at 7:25 AM, in room [ROOM NUMBER], the DON was asked to explain the water in the floor. The DON stated, .what is this water? I can't leave this room because a resident could slip and fall . 3. Observations on the 100 hall on 9/10/18 at 10:29 AM, revealed the janitor closet door was unlocked with (named all purpose cleaning solution) in the closet. Observations on the 100 hall on 9/11/18 at 11:44 AM, revealed the same janitor closet was unlocked with a (named floor cleaner) in the closet. Interview with the DON on 9/11/18 at 11:49 AM the DON was asked if the door should be locked. The DON stated, Yes, it should. The DON was asked if the room contained chemicals. The DON stated, Yes.",2020-09-01
548,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,607,D,1,0,BRJH11,"> Based on review of facility policy, and interview, the facility abuse policy failed to accurately identify the reporting time of an abuse allegation. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility policy failed to .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .",2020-09-01
549,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,609,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the investigation documentation, and interview, the facility failed to report an allegation of abuse immediately or no later than 2 hours for 3 residents (#4, #8, #9) of 7 residents reviewed for abuse. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation documentation involving Resident #4 revealed the staff to resident abuse allegation occurred on 10/21/17 at 6:00 PM and the Administrator was notified on 10/22/17 at 4:00 PM, 22 hours after the occurrence. The State Agency was notified on 10/23/17 at 4:47 PM, 46 3/4 hours after the occurrence. The facility failed to report the abuse allegation to the Administrator and the State Agency immediately or not later than 2 hours. Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility failed to timely report an allegation of abuse to the Administrator and the State Agency. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/30/17 at 7:20 PM revealed .Received result of Left shoulder x-ray. Results read, fracture involving distal clavicle with minimal displacement. Message sent to NP (Nurse Practitioner). Call placed to on call for primary physician. On call MD (Medical Doctor) returned call and order received to place a sling to LUE (Left Upper Extremity) and leave in place until further notice . Review of facility investigation documentation revealed the Administrator was not notified on 11/30/17 when the facility received Resident #8's x-ray results. Interview with the Administrator and Director of Nursing (DON) on 1/23/18 at 3:15 PM in the Administrator's office confirmed the Administrator and the State Agency were not notified of Resident #8's injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/6/17 at 6:12 AM for Resident #9 revealed .New order for xray of left humerus and left ulnar radial on 11/6/17 for swelling and discoloration . Medical record review of a Nursing Progress Note dated 11/7/17 at 2:31 AM for Resident #9 revealed .On 11/6 residents x-ray results came back around 930p (PM) showing Acute moderate displaced (L) (Left) humeral neck fracture. No fracture, destructive [MEDICAL CONDITION] or other abnormalities of the (L) forearm. Made DON and night time supervisor aware . Further review revealed at 10:00 PM the on-call physician had been notified and at 10:20 PM the resident's daughter had been notified. Medical record review of an assessment dated [DATE] signed by the Attending Physician revealed Resident #9 had an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Review of the facility investigation documentation and the medical record revealed the Administrator had not been notified of the xray results, received by the facility on 11/6/17 at around 9:30 PM, until the morning of 11/7/17, when the incident was reported to the State Agency. Interview of the facility Administrator and DON on 1/23/18 at 3:15 PM in the Administrator's office, confirmed the Administrator and the State Agency were not notified of the injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement.",2020-09-01
550,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,656,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to develop a comprehensive plan of care for 1 resident (#9) of 9 sampled residents. The findings included: Review of facility Policy and Procedure MDS/Care Plans undated, revealed .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychological needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence .Procedure .When making decisions about the care plan .a. Determine whether the problem needs an intervention. b. Evaluate the resident's goals, wishes, (advance directives), strengths and needs. c. Design interventions that address cause, not symptoms. d. Establish which items need further assessment or review . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Medical record review revealed an assessment of Resident #9 signed by the Attending Physician dated 11/7/17 of an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Medical record review of the Plan of Care initiated 9/2/16 and revised on 11/17/17 revealed no objectives, goals, or interventions to direct staff in providing care and services to Resident #9 whose condition was compromised after a fracture and who had a [DIAGNOSES REDACTED]. Interview with the Administrator and the Director of Nursing in the Administrator's office on 1/24/18 at 11:30 AM confirmed the care plan for Resident #9 failed to identify objectives, goals, and interventions to direct the staff in the care of the resident with a compromised condition.",2020-09-01
551,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2017-03-29,225,D,0,1,M4T411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report alleged abuse timely to the Department of Health and failed to provide a safe environment during the investigation of alleged abuse for 1 resident (#41) of 3 residents reviewed for abuse. The findings included: Review of the facility's Abuse of Residents Policy and Procedure (undated) revealed .Identification: .The resident might: have bruises .Facility employees, who have been accused of or are suspected of resident abuse, will be immediately suspended without pay and subject to dismissal and possible criminal prosecution pending outcome of an investigation. If the allegations are unsubstantiated, the employee will be reinstated and may be paid for the time out due to the suspension. The facility shall immediately submit to the Department of Health or notice of the suspension of the affected staff person(s), as appropriate as part of the event report . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #41 was moderately impaired cognitively, required moderate assist of 2 staff to ambulate in her room, and was frequently incontinent of urine. Review of the facility's documentation of an ongoing investigation revealed on 3/26/17 at approximately 11:30 PM, the Administrator was notified of an allegation of abuse involving Resident #41, and Certified Nurse Assistant (CNA) #1. Continued review revealed the CNA was sent home when the allegations were reported. Interview with Resident #41 on 3/29/17 at 2:25 PM, revealed the resident was sleepy and unable to answer questions appropriately. Interview with Resident #201 (Resident #41's roommate with a BIMS score of 15 out of 15 indicating the resident is cognitively intact) on 3/29/17 at 2:30 PM, in the resident's room revealed Resident #201 was present when Resident #41 was allegedly abused by CNA #1 on Sunday night. Continued interview revealed Resident #41 was ambulating from the bathroom to the bed when CNA #1 entered the room, .grabbed the resident's wheel chair from over there by the closet, threw her in it .made it rough, instead of letting her ease into it .(CNA #1 told Resident #41) If you don't sleep and keep getting up, I'm going to put you by the desk all night . Review of the written statement from Registered Nurse (RN) #1 revealed .pts (patient) Roommate stated CNA said very nasty things to (Resident #41) and was very mean to her . Interview with the Administrator on 3/29/17 at 3:00 PM in the conference room confirmed the facility failed to notify the Department of Health of the alleged abuse within 2 hours. Continued interview revealed CNA #1 was allowed to return to work and provided care for Resident #41 on 3/28/17. Further interview confirmed the facility's investigation was ongoing and the facility had not interviewed the staff working when the alleged abuse happened, prior to allowing CNA #1 to return to work at the facility.",2020-09-01
552,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,550,D,0,1,X9ZT11,"**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 dignity for 2 of 10 residents (Resident #193 and Resident #209) with catheters. Findings include: Review of the facility policy Dignity undated revealed, .Demeaning practices and standards of care that compromise dignity will not be allowed, for example: helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #193's Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Observations of Resident #193 in the resident's room on 5/1/18 at 9:55 AM, at 10:50 AM and at 12:10 PM revealed the resident's catheter drainage bag was not covered with a dignity bag. Medical record review revealed Resident #209 was admitted to facility on 3/23/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #209 dated 4/20/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Observations of Resident #209 on 5/1/18 at 9:39 AM and on 5/1/18 at 10:52 AM revealed the resident's catheter bag was hanging on the left side of the bed facing the door not covered with a dignity bag, the dignity bag was attached to the walker at the foot of the bed. Interview with Registered Nurse (RN) #1 on 5/1/18 at 12:25 PM at the South II nurse station confirmed catheter bags should always be covered with a dignity bag. Further interview confirmed catheter drainage bags for Resident #193 and Resident #209 should have been covered with a dignity bag. Interview with Director of Nursing (DON) on 5/2/18 at 9:40 AM at the South II nurse station confirmed catheter bags should be covered with a dignity bag at all times.",2020-09-01
553,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,558,D,0,1,X9ZT11,"**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 keep the call light within reach for 1 of 16 residents (Resident #242) observed on the 400 hall. Findings include: Review of facility policy, Call [NAME] System undated, revealed, .It is the policy of the facility to make every effort to respond to the residents' requests and needs .The call bell will be placed within reach when the resident is in bed or sitting in a chair in the room . Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #242 had a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist of one person to transfer or walk in the room. Observations on 5/2/18 at 1:24 PM and at 3:10 PM revealed Resident #242 sitting in the recliner in her room. Continued observation revealed the call light was looped on the bed rail and out of reach of the resident. Observation and interview with Licensed Practical Nurse (LPN) #7 on 5/2/18 at 3:20 PM in Resident #242's room revealed the resident was sitting in the recliner. Continued observation revealed the call light was looped on the bed rail and out of reach of the resident. Interview with LPN #7 confirmed the facility failed to keep the call light within reach for Resident #242.",2020-09-01
554,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,657,D,0,1,X9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview ,the facility failed to ensure care plans were updated for 3 of 68 residents (Resident # 164, Resident # 209, and Resident #253) reviewed. Findings include: Review of facility policy MDS/Care Plans undated, revealed .Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition .when the desired outcome has and/or has not been achieved .when the resident has been readmitted to the facility from the hospital .at least quarterly . Medical record review revealed Resident #164 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #164 to have a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Medical record review of physician's orders [REDACTED].contact isolation for [DIAGNOSES REDACTED]icile (infection of the bowel) . Medical record review of Resident #164's care plan dated 3/1/18 revealed no revision or updates for [DIAGNOSES REDACTED]. Medical record review revealed Resident #209 was admitted to facility on 3/23/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #209 dated 4/20/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Medical record review of lab results for Resident #209 dated 4/16/18 revealed positive stool results for [MEDICAL CONDITION]. Medical record review of physician's orders [REDACTED].contact isolation/[MEDICAL CONDITION] every shift . Medical record review of Resident #209's care plan dated 3/23/18 revealed the facility failed to update the care plan for [MEDICAL CONDITION] or contact isolation. Interview with the MDS Director on 5/2/18 at 4:34 PM in the business office confirmed care plans were updated daily and Resident #164's and Resident #209's care plan should have been updated due to [MEDICAL CONDITION] and contact isolation. Interview with the Director of Nursing (DON) on 5/2/18 at 4:23 PM in the business office confirmed she would expect the care plan to be updated to reflect [MEDICAL CONDITION] and contact isolation. Medical record revealed Resident #253 was admitted to the facility on on 2/13/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change MDS dated [DATE] revealed Resident #253 had a BIMS score of 10, indicating moderate cognitive impairment. The resident required extensive physical assistance of 1 person for bed mobility, transfers, walking in room, locomotion on/off unit and toileting. Continued review revealed Resident #253 was not steady and only able to stabilize with staff assistance. Further review revealed the resident had had falls to occur since admission. Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #253 received a score of 44, indicating a high fall risk. Medical record review of a Facility Incident Report revealed Resident #253 had a fall on 3/18/18 at 11:10 PM in her room resulting in a [MEDICAL CONDITION]. Medical record review of the care plan revised 4/17/18 revealed Resident #253 was identified at risk for falls. Further review revealed no additional interventions after the resident's fall on 3/18/18. Interview with the DON on 5/3/18 at 2:37 PM in the conference room stated the intervention put in placed after Resident #253 fell on [DATE] was for Physical Therapy. The DON confirm the facility failed to updated the care Ppan after a fall for Resident #253.",2020-09-01
555,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,761,D,0,1,X9ZT11,"**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 store wound cleanser in a locked medication cart for 1 of 18 residents (Resident #201) reviewed on the 500 hall. Findings include: Review of facility policy Storage of Medications - General undated, revealed .Medication rooms, carts and medication supplies are locked or attended by person with authorized access . Medical record review revealed Resident #201 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on 4/30/18 at 9:00 AM and at 12:28 PM in Resident #201's room revealed a bottle of wound cleanser on the bedside table. Observation and interview with Licensed Practical Nurse (LPN) #8 on 4/30/18 at 12:34 PM in Resident #201's room revealed a bottle of wound cleanser on the bedside table. Continued interview with LPN #8 stated It shouldn't be there and confirmed the facility failed to keep the wound cleanser in a locked medication cart.",2020-09-01
559,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,880,D,0,1,X9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, interview, and medical record review, the facility failed to follow transmission based precautions and hand washing protocols between residents during meal tray pass on the 200 hall and South skilled hall; failed to change a PICC (peripherally inserted central catheter) dressing timely for 1 of 5 sampled residents (Resident #109) requiring dressing changes. Findings include: Review of facility policy Isolation - Categories of Transmission - Based Precautions revised (MONTH) 2012 revealed, .Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infections status. Transmission - Based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Examples of infections requiring Contact Precautions include .Diarrhea associated with [MEDICAL CONDITIONS] . Observation of tray pass for lunch on 4/30/18 from 12:25 PM-12:40 PM on the 200 hall revealed Certified Nurse Aide (CNA) #5 delivered a meal tray to the resident in room [ROOM NUMBER] [NAME] Continued observation revealed the door to room [ROOM NUMBER] had personal protective equipment (PPE) on it and a sign indicating to use contact precautions before entering the room. Continued observation revealed CNA #5 entered the residents room without any PPE in use, placed the meal tray on the over bed table, adjusted the residents bed and table without gloves in use. Interview with CNA #5 on 4/30/18 at 12:27 PM in the 200 hall outside of room [ROOM NUMBER] A was asked if she was supposed to use PPE when entering room [ROOM NUMBER] and stated, They told me he was just a set up. Further interview when asked about the PPE on the door and the sign for contact precautions and why she failed to use PPE when entering the room CNA #5 stated, I should have. I know better. I was in a hurry I guess. Interview with Licensed Practical Nurse (LPN) #8 (nurse for resident in 125 A) on 4/30/18 at 12:30 PM at the 200 nurse station confirmed the resident was on contact isolation precautions for [MEDICAL CONDITION]. Continued interview revealed when asked when staff were to use PPE, the LPN stated, Every time you enter the room. Not using it is not an acceptable practice. Review of facility Hand Washing Policy undated, revealed, .Hand washing is an effective method for prevention and control of infection .Hands should be washed .Before eating or handling food .Before direct patient contact .After contact with objects .located in the patient's environment . Observation of tray pass for lunch on 4/30/18 from 12:41 PM-12:55 PM on the South skilled hall revealed Housekeeper (HK) #1 carried a meal tray into room [ROOM NUMBER] B, placed the tray on the over bed table and positioned it close to the resident. Continued observation revealed the HK exited the room without washing or sanitizing her hands. Continued observation revealed the HK obtained a meal tray from the food cart and carried it to room [ROOM NUMBER] A, placed it on the over bed table, assisted with set up, cut the food using the residents utensils and positioned the table closer to the resident. Further observation revealed HK #1 exited the room without washing or sanitizing her hands. Continued observation revealed the HK went back to the food cart in the hall wiped her nose and touched her hair with her left hand, obtained a meal tray and carried it to room [ROOM NUMBER] [NAME] Further observation revealed HK #1 was seated at the bedside assisting the resident with her pureed diet. Interview with HK #1 on 4/30/18 at 1:00 PM on the South skilled hall by room [ROOM NUMBER] when asked when she was to wash her hands stated, Before and after I start feeding. The HK was asked if she was trained in hand washing and stated, Yes, I forgot what I'm supposed to do. When asked what she was supposed to do she stated, I guess I should wash my hands. Further observation revealed HK #1 continued to feed the resident without washing or sanitizing her hands. Interview with LPN #9 (Unit Manager for the South skilled hall) on 4/30/18 at 1:07 PM in the South skilled hall by room [ROOM NUMBER] when explained the actions of HK #1 stated, They know better than that. Continued interview with the LPN confirmed hand washing should be done between contact with each resident, and definitely before assisting a resident with dining. Interview with Registered Nurse (RN) #4 (Infection Control Preventionist) on 5/3/18 at 4:10 PM in her office when notified of the tray pass observations on 4/30/18 stated she was already aware of the concerns. Continued interview with RN #4 confirmed the facility failed to follow transmission based precautions, and proper hand washing to prevent contamination to the residents. Review of facility policy Central Venous Catheter Dressing Changes revised (MONTH) (YEAR), revealed .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (as needed) (when wet, soiled, or not intact) . Medical record review revealed Resident #109 was readmitted to facility on 4/25/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set for Resident #109 dated 3/28/18 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Medical record review of Physician order [REDACTED].#109 revealed .change PICC line dressing every day shift every Friday . Medical record review of the care plan dated 4/26/18 for Resident #109 revealed .Change PICC line dressing per facility protocol . Observation of on 4/30/18 at 10:29 AM, 12:10 PM, and 4:00 PM and on 5/1/18 at 9:31 AM and 2:29 PM of Resident #109 in her room revealed the resident had a PICC line dressing to upper right arm dated 4/20/18. Interview with Resident #109 on 4/30/18 at 10:29 AM in the resident's room confirmed the PICC line dressing was dated 4/20/18, and .it hasn't been changed . Interview with LPN #1 on 5/1/18 at 2:29 PM in Resident #109's room confirmed the PICC line dressing to Resident #109's right upper arm was dated 4/20/18. Further interview with LPN #1 confirmed PICC line dressings were changed weekly on Fridays by the treatment nurse. Interview with LPN #2 (treatment nurse) responsible for dressing changes, on 5/1/18 at 2:54 PM in the South 2 nurse's station confirmed PICC line dressings are changed on Fridays. LPN #2 stated .I'm sure I changed it Friday, I must have put the wrong date on it . Interview with the Director of Nursing (DON) on 5/2/18 at 9:43 AM in the South 2 nurse's station confirmed PICC line dressings were changed weekly or as needed. Further interview with the DON confirmed she would expect staff to change the dressings at least weekly or as needed if the dressings become soiled or dirty.",2020-09-01
560,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,908,D,0,1,X9ZT11,"Based on review of the manufacturer's recommendations, observation and interview, the facility dietary department failed to maintain the dish machine in safe operating condition, and failed to maintain the dish room door in a safe manner. Findings include: Review of the manufacturer's recommendations revealed the minimum wash temperature was 140 degrees Fahrenheit (F) and the minimum rinse temperature was 120 degrees F. Observation on 4/30/18 at 11:38 AM in the dietary department revealed the resident mid-day meal tray line was in progress. Further observation revealed the dietary staff were manually washing dishes, used for breakfast, in the 3 compartment sink. Interview with the Dietary Manager on 4/30/18 at 11:38 AM in the dietary department revealed the dish machine sanitizer solution would not prime, therefore not dispense, in the dish machine and the service company had been contacted. Observation on 5/1/18 at 2:50 PM of 7 consecutive cycles of the dish machine in the dietary department dish room, included 5 racks with resident meal service trays and 2 racks with plate domes and bases, revealed the wash temperature went from 130 degrees F and dropped to 126 degrees F. Further observation revealed the rinse temperature was 128 degrees F for all 7 racks processed and the temperature gauge never moved. Interview with the Dietary Manager on 5/1/18 at 2:50 PM in the dish room confirmed the wash and rinse temperatures did not reach the minimum level recommended by the manufacturer. Observation on 5/2/18 at 12:30 PM in various resident hallways revealed the resident meals were served in styrofoam or paper containers. Observation on 5/2/18 at 6:45 PM in the dietary department dish room revealed the interior bottom section of the dish room door was rusted and some areas were gone. Interview with the Dietary Manger on 5/2/18 at 6:45 PM in the dietary department dish room confirmed the dish machine failed to reach the minimum wash and rinse temperatures specified by the manufacturer therefore the resident meals were served on styrofoam or paper. Further interview confirmed the dish room door leading into the dining room bottom section was rusted.",2020-09-01
561,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2019-05-08,583,D,0,1,G8QZ11,"**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 secure the personal privacy and confidentiality of 1 narcotic book containing narcotic sign out sheets for Resident #48. The findings include: Review of facility policy, Confidentiality of Information, undated revealed .Our facility shall treat all resident information confidentially and shall access protected information only as necessary . Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report revealed .[MEDICATION NAME] HCI ([MEDICATION NAME]) Tablet 10 MG (milligrams), Give 1 tablet by mouth every 6 hours as needed for pain related to ACUTE HEMATOGENOUS OSTEO[DIAGNOSES REDACTED], RIGHT FEMUR . Observation of the medication cart on 5/8/19 at 4:40 PM on the Skilled Hall revealed the medication cart was unattended and the narcotic sign out book was opened exposing Resident #48's name and medication information. Further observation of the narcotic sign out book revealed the medication for Resident #48 was signed out on 5/8/19 at 4:00 PM. Observation on 5/8/19 at 4:42 PM on the Skilled Hall revealed Registered Nurse (RN) #2 walking casually past the medication cart carrying linens then walked into a resident room and closed the door. Interview with RN #2 on 5/8/19 at 4:47 PM in the Skilled Hall stated .in the real world I would have put everything away (close narcotic sign out book) . Interview with the Director of Nursing on 5/8/19 at 5:20 PM in her office confirmed .the narcotic sign out book should be closed when unattended .",2020-09-01
563,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-07-18,600,D,1,0,9S4C11,"**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 prevent physical abuse of 1 (Resident #2) of 4 residents reviewed for abuse/neglect. Findings include: Review of facility policy Abuse, Neglect, and Exploitation of Residents, revealed .The facility will not condone resident abuse by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends or other individuals .All personnel are required to promptly report any incident or suspected incident of resident abuse .Upon receiving reports of physical or sexual abuse the nursing supervisor will immediately examine the resident .An immediate investigation will commence and a stated and signed statement from the person reporting the incident will be obtained .It is the responsibility of all staff to identify inappropriate behavior towards residents, which may include but is not limited to use of derogatory language; rough handling of residents; ignoring residents while giving care; directing residents who need toileting assistance to urinate/defecate in their clothing, etc .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm a resident. This includes but is not limited to hitting, slapping, pinching, spitting at, kicking, etc .The facility will provide abuse prohibition training to all new employees and volunteers. All staff will receive this training on an annual basis . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 0 on the Brief Interview for Mental Status indicating he was unable to answer the questions. Continued review of the MDS revealed Resident #2 required extensive assistance of 2 people for transfers, dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of facility investigation of a written statement by Certified Nurse Aide (CNA) #1 revealed she was .in the middle of a round walking up to the front when she heard yelling. She heard a nurse yell at a resident as she looked down the hall and heard her say let go of my necklace you stupid [***] . She had him by the hands and had bite him was continuing yelling had his hands up to his neck and this point I had went back to my hall. I came back up to the front to her walking out the doors and was gone for about 30 minutes. Continued review revealed a clarification note by the Administrator in which CNA #1 was asked if she saw Licensed Practical Nurse (LPN) #1 actually bite down with teeth showing or did she see nurse's mouth on resident's hand. Further review revealed CNA #1 did not see the nurse actually bite but rather her lips on the resident's hand. Further review revealed the Administrator asked CNA #1 if she saw the resident had a grip on the nurse and CNA #1 said it appeared the resident had a hold of something with the nurse. Continued review revealed the Administrator asked CNA #1 if the nurse had the resident by the hands or the resident had the nurse by the hands and she said it looked like the nurse had the resident but couldn't see that clearly to say 100%. Review of facility investigation of an interview dated 6/4/18 between the Administrator, Acting Assistant Director of Nursing, and LPN #1 revealed LPN #1 stated a resident had his hands around her neck. Continued review revealed the Administrator asked if the LPN did anything inappropriate to the resident and LPN #1 stated I yelled at him to let me go. Further interview revealed the Administrator asked LPN #1 if she touched the resident in any way and she stated she had bitten the resident because I panicked and didn't know what to do because he was choking me. Continued interview revealed the Administrator clarified with LPN #1 if she bit down or put her mouth on resident hand and she said she put her mouth on his hand and her teeth did make contact with resident's hand. Further interview revealed the Administrator asked how the resident got his hands around her neck and LPN #1 stated I was behind him locking his wheelchair and he reached behind him and grabbed my throat. I didn't know how to get free. We were in the hallway and nobody was coming to help. Continued interview revealed the Administrator watched the video there were several staff members in the hallway and the description of the event did not make sense with the nurse being able to bite the resident while his hands were around her neck. Further interview revealed LPN #1 was suspended immediately. Review of facility investigation of a written statement by LPN #1 revealed I went up to the resident to help move him. I reach around the back of his wheelchair to unlock his wheels to move him when he reached backward and grabbed me by the neck. I panicked at that time and tried to release his hands from me but was unable causing me to panic further. I was at him to let go but he would not. Nobody was coming to help so I bite his hand to try and see if he would let go. He loosed his grip at that time and I was able to slip away. He had the necklace I had on in his hands so I grab the necklace and got it away from him. Interview with the Administrator and DON on 7/18/18 at 10:40 AM in the conference room revealed revealed there were no teeth marks, abrasions, or skin issues with the resident. Further interview revealed LPN #1 stated her teeth made contact with his hand because she had panicked. Continued interview revealed the Administrator terminated LPN #1 to err on the side of the resident even though she could not prove the nurse bit the resident because there were no teeth marks, but the nurse had yelled at the resident and called him a [***] which the Administrator confirmed constituted verbal abuse.",2020-09-01
565,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2020-01-09,686,D,1,0,5J8E11,"**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 complete and weekly assessments for pressure ulcers for 1 of 3 sampled residents (Resident #2) reviewed with pressure ulcers. The findings include: The facility's undated policy titled, Skin Care Guideline, documented, .When an open area is identified .Document evaluation of wound in electronic medical record including .Location and staging .Size (length .width .depth .Weekly skin evaluations are completed and documented . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan documented, .Focus .11/23/2019 stage 2 right ankle .Interventions .Weekly Wound Assessment . The Progress Notes dated 11/22/19 documented, .resident has open area on right outer foot .measures 0.4 cm (centimeters) x (by) 1 cm . There was no stage of the pressure injury. The Progress Notes dated 12/5/19 documented, .has stage 2 pressure ulcer on right mid outer foot, white center with pink edges, no drainage . There were no measurements of the pressure injury. The Progress Notes dated 1/2/20 documented, .outer right foot .measures 0.5 cm x 0.5 cm . There was no stage of the pressure injury. The Progress Notes dated 1/6/20 documented, .wound to right outer foot is 1 cm x 1 cm . There was no stage of the pressure injury. Medical record review from 11/22/19 - 1/6/20, showed the only wound assessments performed were on 11/22/19, 12/5/19, 1/2/20, and 1/6/20. Observation in the resident's room on 12/27/19 at 10:07 AM, showed Resident #2 had 2 small open areas to the right outer foot. The facility was unable to provide documentation that weekly wound assessments and complete wound assessments with measurements and staging were performed for Resident #2's pressure injury. During an interview conducted on 12/27/19 at 12:10 PM, the Wound Care Nurse was asked about Resident #2's pressure injury on her right foot. The Wound Care Nurse stated, .started (MONTH) 23rd .one is almost healed .still working on the other spot .is a stage 2 . During a phone interview conducted on 1/9/20 at 9:30 AM, the Director of Nursing (DON) confirmed weekly wound assessments and complete wound assessments with measurements and staging were not performed and stated, .not getting assessed correctly .",2020-09-01
566,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2019-08-27,759,D,0,1,HPLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings include: 1. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] HandiHaler Capsule 18 MCG (Microgram) .2 puff inhale orally one time a day . Observations in Resident #58's room on 8/27/19 beginning at 8:27 AM, revealed LPN #1 administered the [MEDICATION NAME] Handihaler to Resident #58. Resident #58 inhaled 1 puff and handed the Handihaler back to LPN #1. LPN #1 stated, That's right, 1 puff. Interview with the Director of Nursing (DON) on 8/27/19 at 4:38 PM, in the DON office, the DON confirmed Resident #58 should have received 2 puffs of [MEDICATION NAME]. The failure of the nurse to administer 2 puffs of the [MEDICATION NAME] resulted in medication error #1. 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Suspension 50 MCG .2 spray in both nostrils one time a day . Observations in Resident #16's room on 8/27/19 at 8:44 AM, revealed LPN #2 administered [MEDICATION NAME] Suspension to Resident #16 with 1 spray to each nostril. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of [MEDICATION NAME] to each nostril. The failure of the nurse to administer 2 sprays of the [MEDICATION NAME] resulted in medication error #2. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of [MEDICATION NAME] to each nostril. The DON was asked if the nurses should administer medications as ordered. The DON stated, Yes, Ma'am.",2020-09-01
567,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2019-08-27,880,D,0,1,HPLV11,"Based on observation and interview, the facility failed to ensure infection control practices to prevent the potential spread of infection in 1 of 1 laundry room. The findings include: Observations in the clean linen room of the laundry room on 8/26/19 at 1:35 PM, revealed a dirty empty mop bucket with a black thick substance on the top and on the bottom of the mop bucket and black thick substance on the wringer of the mop bucket. Interview with the Environmental Manager on 8/26/19 at 1:40 PM, in the clean linen room of the laundry room, the Environmental Manger was asked if the mop bucket was dirty. The Environmental Manager stated, .Yes . The Environmental Manager was asked if the dirty mop bucket should have been stored in the clean linen room. The Environmental Manager stated, No. Observations in the washing machine room of the laundry room on 8/26/19 at 1:45 PM and 2:55 PM, and on 8/27/19 at 1:45 PM and 2:55 PM, revealed an exhaust fan with thick white and gray debris stuck to the fan. The gray debris was blowing over the clean, uncovered linen. Observations in the dryer machine room of the laundry room on 8/26/19 at 1:55 PM and 3:00 PM, revealed uncovered clean dry laundry piled in wire baskets. A clean sheet was hanging out of the basket touching the floor. Interview with the Environmental Manager on 8/26/19 at 3:04 PM, in the dryer room of the laundry room, the Environmental Manager was asked if the laundry in the wire baskets was clean. The Environmental Manager stated, Yes. Observations in the clean linen room of the laundry room on 8/27/19 at 1:40 PM, revealed a dirty empty mop bucket with a black thick substance on the rim of a mop bucket and on the bottom of the mop bucket. Interview with the Environmental Manager on 8/27/19 at 2:57 PM, in the drying machine room of the laundry room, the Environmental Manager was asked if the clothes in the uncovered baskets, and if the sheet touching the floor were clean. The Environmental Manager stated, Yes . the clean clothes should be covered and not touching the floor . Interview with the Environmental Manager on 8/27/19 at 3:03 PM, in the washing machine room of the laundry room, the Environmental Manager was asked what was on the exhaust fan, and what was blowing off of the fan. The Environmental Manager stated, .it's coated with dirt and dust, shouldn't be blowing in the room .",2020-09-01
568,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,164,D,0,1,QOES11,"Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses failed to provide confidentiality of medical records during medication pass observations. The findings included: The facility's SAFEGUARDING PROTECTED HEALTH INFORMATION . policy documented, .Safeguards for Written Uses .C. Active Clinical Records shall not be left unattended on the nurses' station desk or other areas where residents, visitors and unauthorized individuals could easily view the records. D. Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI (Protected Health Information) shall not be left open and/or unattended . Observations at the medication cart in front of Resident #59's room on 10/3/17 beginning at 9:10 AM, revealed LPN #3 was getting ready to prepare medications for Resident #59 with the computer screen open with resident information visible, stepped away from the medication cart and wheeled a resident down the hall. LPN #3 left the computer screen on with the resident information still visible in the hallway. LPN #3 then walked down the hall to obtain a medication and left this screen on visible again. Interview with the Director of Nursing (DON) on 10/4/17 at 9:05 AM, in the DON office, the DON was asked what should be done with the computer screen when walking away from the medication cart. The DON stated, .should close it or lock the screen.",2020-09-01
569,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,241,D,0,1,QOES11,"Based on observation and interview, the facility failed to provide care in a manner that ensured the residents' dignity, respect, and quality of life was maintained when 1 of 10 (Certified Nursing Assistant (CNA) #1) staff members stood over a resident while assisting them to eat during dining observations. The findings included: Observations in Resident #41's room on 10/2/17 at 12:25 PM, CNA #1 stood over Resident #41 and fed the resident. Observations in Resident #43's room on 10/3/17 at 7:57 AM, CNA #1 stood over Resident #43 and fed her. Interview with the Director of Nursing (DON) on 10/3/17 at 3:50 PM, at the entrance to the Administrative office, the DON was asked if it was acceptable to stand over a resident while feeding the resident. The DON stated, No ma'am.",2020-09-01
570,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,280,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to review the care plan quarterly for Behaviors, Depression, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION] medication use, and Diuretic medication use for 1 of 14 (Resident #36) sampled residents reviewed of the 16 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/16/15 documented, .(Named Resident #35) displays sexually inappropriate behavior, and makes false allegations against staff/residents . with a goal date of 5/14/17. The care plan dated 8/8/16 documented, .Mr. (Named Resident #35) had a [DIAGNOSES REDACTED]. with a goal date of 5/14/17. The care plan dated 7/31/16 documented, .Mr. (Named Resident #35) has a DX. (diagnosis) of [MEDICAL CONDITIONS] . with a goal date of 5/14/17. The care plan dated 2/20/17 documented, .Mr. (Named Resident) has a DX of Diabetes type II and is insulin dependent and at risk for hypo/hyperglycemic (high/low blood glucose) episodes and or complications secondary to diabetes He is often non-compliant with diet . with a goal date of 5/14/17. The care plan dated 2/20/12 documented, .(Named Resident) is at risk for side effects from [MEDICAL CONDITION] medication drug use RT (related to)/Dx. of Depression . with a goal date of 5/14/17 The care plan dated 2/20/12 documented, .(Named Resident) is at risk for dehydration r/t use of diuretics . with a goal date of 5/14/17. Interview with the Minimum Data Set (MDS) Coordinator on 10/3/17 at 2:40 PM, in the MDS office, the MDS Coordinator was asked about the goal date of 5/14/17 for the care plan related to inappropriate sexual behaviors. The MDS Coordinator stated, It should have been updated on 6/13/17. The MDS Coordinator was asked if the care plan had been reviewed timely. The MDS Coordinator stated,That particular one was not . The MDS was asked about the care plan related to the [DIAGNOSES REDACTED]. The MDS Coordinator stated, It was not updated either. The MDS Coordinator was asked when it should have been reviewed . The MDS Coordinator stated, Same date 6/13/17. He is behind on his MDS. The MDS Coordinator was asked if the care plans should have another review date of 9/13/17. The MDS Coordinator stated, Yes, ma'am. The MDS Coordinator was asked about the care plan related to Diabetes Mellitus with a goal date of 5/14/17. The MDS Coordinator stated, Same case on that one. The MDS Coordinator was asked about the care plan related to [MEDICAL CONDITION] medication side effects with a goal date of 5/14/17. The MDS Coordinator stated, It is the same. The MDS Coordinator was asked about the care plan related to diuretic use with a goal date of 5/14/17. The MDS Coordinator stated, It is the same. The MDS Coordinator confirmed these care plans were not reviewed quarterly.",2020-09-01
571,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,309,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide physician's orders for 1 of 1 (Resident #45) sampled resident reviewed receiving hospice and 1 of 1 (Resident #68) sampled resident reviewed receiving [MEDICAL TREATMENT] services of the sampled residents. The findings included: 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was receiving hospice care. Review of the physician orders dated 9/27/17 revealed there were no current orders for hospice. Interview with Licensed Practical Nurse (LPN) #2 on 10/3/17 at 2:48 PM, at the central nurses station, LPN #2 was asked if Resident #45 was on hospice. LPN #2 stated, Yes. LPN #2 was asked if there were current orders for hospice. LPN #2 stated, I don't see one. LPN #2 was asked if there should be current orders for hospice. LPN #2 stated, Yes. 2. Medical record review revealed Residet #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] and the quarterly MDS dated [DATE] received [MEDICAL TREATMENT]. The care plan dated 1/27/16 documented Resident #68 required [MEDICAL TREATMENT]. Review of the physician orders for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed there were no current orders for [MEDICAL TREATMENT]. Interview with the Director of Nursing (DON) on 10/3/17 at 11:35 AM, in the DON office, the DON confirmed there were no current orders for [MEDICAL TREATMENT] for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR).",2020-09-01
573,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,441,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses failed to follow appropriate infection control practices to prevent the potential spread of infection during medication pass observations. The findings included: The facility's Hand Hygiene Care Audit policy documented, .3. Hand washing is done every time you remove gloves .9. Washes hands every time gloves are removed . Observations at the medication cart in front of Resident #62's room on 10/3/17 beginning at 11:08 AM, revealed LPN #4 cleaned a glucometer and removed her gloves, without performing hand hygiene. LPN #4 then prepared insulin at the medication cart, went into Resident #62's room, applied gloves without performing hand hygiene, and administered insulin to Resident #62. Observations in Resident #16's room on 10/3/17 beginning at 12:39 PM, revealed LPN #4 took a nebulizer mask out of a labeled ziplock bag and there was clear solution in the reservoir. LPN #4 emptied this out into tissues, without rinsing the reservoir. LPN #4 poured the unit dose of [MEDICATION NAME] into the reservoir and administered the breathing treatment. After the breathing treatment was administered, LPN #4 dried the reservoir with a clean tissue, but did not rinse the reservoir. Interview with LPN #4 on 10/3/17 at 12:46 PM, Resident #16's room, LPN #4 was asked what the solution was that she emptied onto the tissues from the reservoir. LPN #4 stated, Was probably some ([MEDICATION NAME] solution) they had put in early this morning, not my shift. Interview with the Director of Nursing (DON) on 10/4/17 at 9:05 AM, in the DON office, the DON was asked what should be done after removing gloves and prior to donning new gloves. The DON stated, Should perform hand hygiene. The DON was asked what should be done with the nebulizer reservoir after completing a nebulizer treatment. The DON stated, Should clean and dry it.",2020-09-01
581,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2017-06-01,309,D,0,1,50PF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to monitor fluid intake for a resident on [MEDICAL TREATMENT] with fluid restrictions for 1 resident (#124) of 2 residents receiving [MEDICAL TREATMENT], of 19 residents reviewed. The findings included: Medical record review revealed Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #124's Care Plan dated 1/6/17 revealed, .(Resident #124) is on fluid restriction 1000 ml (milliliters) per [MEDICAL TREATMENT] .Evaluate .hydration status .Provide diet and liquids as ordered . Medical record review of the Physician's Recapitulation Orders for (MONTH) (YEAR) revealed, .1000 CC (cubic centimeters) FLUID RESTRICTION .600 CC/DAY FROM DIETARY .240 CC/DAY FROM CAN OF NEPHRO (liquid therapeutic nutrition for residents on [MEDICAL TREATMENT]) .160 CC/DAY FROM NURSES WITH MEDICATIONS .NEPHRO -1 CAN DAILY .D[NAME]UMENT PERCENT CONSUMED .PROSTAT (liquid protein supplement) - 40CC THREE TIMES DAILY .D[NAME]UMENT PERCENT CONSUMED .[MEDICAL TREATMENT] TUESDAY, THURSDAY, SATURDAY . Medical record review revealed no documentation regarding Resident #124's percentage of dietary fluid intake. Interview with Certified Nursing Assistant (CNA) #1 on 6/1/17 at 8:30 AM on the C Hallway confirmed, .nurses tell us how much they can have .I don't know the limit on anybody .we set it (tray) up .pick them up . Further interview confirmed CNA's did not document the percent of dietary fluids consumed for Resident #124. Interview with Licensed Practical Nurse (LPN) #1 on 6/1/17 at 11:40 AM at the Harbor Side Nurse's Station, confirmed the facility was not monitoring Resident #124's fluid intake. Interview with the facility's Corporate Nurse Consultant on 6/1/17 at 1:42 PM in the Director of Nurse's office confirmed, .fluids are broken down with meals (for residents on fluid restrictions) . we're charting for one (resident) .on paper .and not the other .there lies the problem . Continued interview confirmed the facility failed to monitor the percent of dietary fluids consumed for Resident #124.",2020-09-01
583,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,693,D,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interview, the facility failed to check the gastric tube placement for 1 resident (#24) of 1 resident observed for medication administration by gastric tube; and failed to follow physician's orders [REDACTED].#43) of 6 residents observed for enteral tube feeding. The findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of facility policy, Medication Administered through an Enteral Tube, effective date 4/4/19, revealed .Procedure .(14) .Verify that the tube is functioning before administering medications, which may include: 14.1 checking gastric residual volume . Observation of a medication administration on 6/24/19, at 8:50 AM, revealed Licensed Practical Nurse (LPN) #2 prepared medication for Resident #24. Continued observation revealed the LPN #2 administered 10 milliliter (ml) water and listened with a stethoscope for placement of the gastric tube. Continued observation revealed the LPN #2 administered the medication. Interview with the LPN #2 on 6/25/19 at 8:35 AM, in the hallway, confirmed she had not the check placement of the gastric tube correctly before administering the medication. LPN #2 confirmed she had not followed the facility's policy to check the gastric residual. Interview with the Director of Nursing (DON) on 6/25/19 at 8:40 AM, in the DON's office, confirmed the gastric residual was to be checked prior to administering medication. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #43 scored a 99 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. Continued review revealed the resident received enteral feeding. Medical record review of the Comprehensive Care Plan dated 4/17/19 revealed the resident required enteral feeding related to swallowing problems and was NPO (nothing by mouth) with the intervention .See MD (Medical Doctor) orders for current feeding orders . Medical record review of dietary notes dated 4/17/19 and 6/24/19 revealed the resident received enteral feeding of [MEDICATION NAME] 1.5 (nutritional supplement) at 45 cubic centimeters per hour (cc/hr) with 30 cc/hr water flushes with no further recommendations. Medical record review of the physician's orders [REDACTED]. Observation of Resident #43 on 6/23/19 at 9:19 AM, 11:55 AM, 12:10 PM, 2:53 PM, and on 6/24/19 at 7:35 AM, and 8:13 AM, in the resident's room, revealed the resident was lying in bed with the Head of the Bed (HOB) elevated 45 degrees. Continued observation revealed the resident had an enteral tube feeding which infused [MEDICATION NAME] 1.5 at 60 ccl/hr and the water flush at 45 cc/hr. Observation of Resident #43 and interview with Registered Nurse (RN) #1 on 6/23/19 at 8:13 AM, in the resident's room, revealed the enteral feeding pump was set to deliver the [MEDICATION NAME] 1.5 at 60 cc/hr with the water flush at 45 cc/hr. Continued interview confirmed the rate of the enteral feeding was not administered at the correct rate as ordered by the Physician. Interview with the DON on 6/24/19 at 11:15 AM, in the DON's office, confirmed the facility failed to administer the tube feeding as ordered by the Physician for Resident #43.",2020-09-01
584,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,880,D,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices during [MEDICAL CONDITION] (surgical formation of an opening into the trachea through the neck to allow passage of air) care for 1 resident (#69) of 1 resident observed for [MEDICAL CONDITION] care. The findings include: Review of the facility policy, Performing [MEDICAL CONDITION] Care, dated (YEAR) revealed .Performed hand hygiene, gathered supplies .removed soiled dressing, discarded in glove .Performed hand hygiene, prepared equipment on bedside table .Opened sterile kit .Opened sterile [MEDICAL CONDITION] dressing package .Opened inner cannula package .Applied sterile glove . Medical record review revealed Resident #69 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 5/16/19 [MEDICAL CONDITION] every day shift and every 24 hours as needed. Observation of Resident #69's [MEDICAL CONDITION] care on 6/25/19 at 10:50 AM, in the resident's room, with Licensed Practical Nurse (LPN) #1 revealed with gloved hands the LPN, removed the [MEDICAL CONDITION], removed the inner cannula, inserted the new inner cannula, removed the gloves, opened and donned sterile gloves without disinfecting the hands. Interview with the Infection Control Nurse on 6/25/19 at 11:07 AM in the conference room, confirmed LPN #1 failed to follow the facility policy and failed to disinfect the hands after glove removal during [MEDICAL CONDITION] care.",2020-09-01
585,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,609,D,1,1,JJ9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to report an allegation of abuse timely to the Administrator and the State Survey Agency for 1 resident (#83) of 26 residents reviewed for abuse. The findings include: Review of the facility's Abuse Policy with an effective date of (MONTH) (YEAR) revealed .Abuse means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury .All alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source .are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Immediately means as soon as possible: 1. Any allegation of abuse within two hours . Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had severe cognitive impairment and had no mood or behavior issues. Further review revealed the resident required limited assistance with transfers, walking in room, and toilet use. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed Resident #10 had severe cognitive impairment and no mood or behavior issues. Further review revealed the resident required limited assistance with transfers and walking in room. Observation of resident #83 on 7/30/18 at 10:40 AM, in her room, revealed her left hand and thumb wrapped with an ace wrap. Interview with Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed when asked why her left hand and thumb were wrapped in an ace wrap, she stated a woman knocked me down over there (pointed at the bathroom door) and it hurt my hand. Interview with Licensed Practical Nurse (LPN) #1 on 7/30/18 at 11:50 AM, at the Harbor side nurse's station, revealed she had been the nurse on duty 7/28/18 and Resident #83 had been involved in a resident to resident altercation with her roommate (Resident #10) on this date. Continued interview revealed Resident #10 pushed Resident #83 down in the residents' room and Resident #83 had to be transferred to the emergency room for evaluation. Review of a nursing progress note for Resident #83 dated 7/28/18 at 1:00 PM revealed .resident stated she was walking back from the bathroom and stopped in front of her room mates television and room mate thought she was messing with her television and pushed resident down to the floor on her buttock . Review of a nursing progress note for Resident #10 dated 7/28/18 at 1:31 PM, revealed .Resident stated I pushed her down cause she was messing with my television . Interview with Resident #10 on 7/30/18 at 12:10 PM, in her room, revealed the resident did not remember having an altercation with Resident #83 on 7/28/18. Interview with the Administrator on 7/31/18 at 2:53 PM, in his office, confirmed he had no knowledge of a resident to resident altercation between Resident #10 and Resident #83. Further interview confirmed the altercation had not been reported to the state agency. Telephone interview with the Director of Nursing on 8/1/18 at 9:49 AM, confirmed she had been notified of a resident to resident altercation between Resident #10 and Resident #83 on 7/28/18. Further interview confirmed the altercation had not been reported to the state agency.",2020-09-01
586,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,610,D,1,1,JJ9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to investigate a resident to resident altercation for 2 residents (#10 and #83) of 26 residents reviewed for abuse. The findings include: Review of the facility's Abuse Policy with an effective date of (MONTH) (YEAR) revealed .Anytime there is any allegation of abuse, neglect, exploitation, injuries of unknown origin or misappropriation, the center must report the alleged violation to the Administrator/DON (Director of Nursing) and initiate an immediate investigation and prevent further potential abuse. Based on the investigation findings, the center will implement corrective actions to prevent recurrence .All investigations shall be conducted by the Administrator/Director of Nursing or subject matter expert . Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment and no mood or behavior issues. Further review revealed the resident required limited assistance with transfers and walking in room. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed Resident #83 had severe cognitive impairment and had no mood or behavior issues. Further review revealed the resident required limited assistance with transfers, walking in room, and toilet use. Observation of Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed her left hand and thumb had an ace wrap in place. Interview with Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed when asked why her left hand and thumb were wrapped in an ace wrap, she stated a woman knocked me down over there (pointed at the bathroom door) and it hurt my hand. Interview with Licensed Practical Nurse (LPN) #1 on 7/30/18 at 11:50 AM, at the Harbor side nurse's station, revealed she was the nurse on duty 7/28/18 and Resident #83 had been involved in a resident to resident altercation on 7/28/18 with her roommate (Resident #10). Continued interview revealed Resident #10 pushed Resident #83 down in the residents' room and Resident #83 had to be transferred to the emergency room for evaluation. Review of a nursing progress note for Resident #83 dated 7/28/18 at 1:00 PM revealed .resident stated she was walking back from the bathroom and stopped in front of her room mates television and room mate thought she was messing with her television and pushed resident down to the floor on her buttock . Review of a nursing progress note for Resident #10 dated 7/28/18 at 1:31 PM revealed .Resident stated I pushed her down cause she was messing with my television . Interview with Resident #10 on 7/30/18 at 12:10 PM, in her room, revealed she had no recollection of an altercation with her roommate on 7/28/18. Interview with the Administrator on 7/31/18 at 2:53 PM, in his office, confirmed he had no knowledge of a resident to resident altercation between Resident #10 and Resident #83. Further interview confirmed the altercation had not been investigated. Telephone interview with the Director of Nursing on 8/1/18 at 9:49 AM, confirmed she had been notified of a resident to resident altercation between Resident #10 and Resident #83 on 7/28/18. Further interview confirmed the altercation had not been investigated.",2020-09-01
587,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,657,D,0,1,JJ9N11,"**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 1 resident (#76) of 26 residents reviewed. The findings include: Medical record review revealed Resident #76 was re-admitted to the facility on [DATE] with Rectal Prolapse and Polyp of Colon. Medical record review of the resident's care plan dated with an onset date of [DATE] revealed the resident's code status was Full Code. Further review revealed the staff was to administer CPR (cardiopulmonary resuscitation) if resident had an arrest. Medical record review of a physician's orders [REDACTED]. Medical record review of a POST (Physician order [REDACTED]. Interview with the Assistant Director of Nurses (ADON) on [DATE] at 3:30 PM, in the ADON's office, confirmed the care plan did not accurately reflect the resident's current code status.",2020-09-01
588,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,550,D,0,1,IXKF11,"Based on policy review, observation, and interview, the facility failed to ensure residents were treated with respect and dignity when they were called Momma, Baby, and Feeder by 2 of 13 (Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1) staff during the dining observation, and were called Honey, Sweetie, and Baby by 1 of 6 (LPN # 2) nurses during medication administration, and when the facility displayed signage that named residents as Feeders. The findings include: 1. The facility's undated S[NAME]IAL SERVICE POLICIES .Dignity . policy documented, .Respecting resident's social status, speaking respectfully .addressing the resident with a name of the resident's choice . 2. Observations in the 2 West Dining Room on 1/7/19 at 12:25 PM, revealed CNA #1 called Resident #33 by the name, Momma. Review of Resident #33's care plan revealed there was no documentation that Resident #33 preferred to be called Momma. 3. Observations in the 2 West Dining Room on 1/7/19 at 12:25 PM, revealed CNA #1 called Resident #72 by the name, Momma. Review of Resident #72's care plan revealed there was no documentation that Resident #72 preferred to be called Momma. 4. Observations in the 2 West Dining Room on 1/7/19 at 12:34 PM, revealed CNA #1 called Resident #66 by the name, Momma. Review of Resident #66's care plan revealed there was no documentation that Resident #66 preferred to be called Momma. 5. Observations in the 2 West Dining Room on 1/7/19 at 12:44 PM, revealed CNA #1 spoke to LPN #1 who was across the dining room and referred to Resident #96 and said, She's a feeder. The dining room was full with other residents. LPN #1 then called Resident #96 Momma. Review of Resident #96's care plan revealed there was no documentation that Resident #96 preferred to be called Momma. 6. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #29 by the name, Baby. Review of Resident #29's care plan revealed there was no documentation that Resident #29 preferred to be called Baby. 7. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #4 by the name, Baby. Review of Resident #4's care plan revealed there was no documentation that Resident #4 preferred to be called Baby. 8. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #41 by the name, Baby. Review of Resident #41's care plan revealed there was no documentation that Resident #41 preferred to be called Baby. 9. Observations in the 2 West Dining Room on 1/8/19 at 7:59 AM, revealed CNA #1 called Resident #21 by the name, Baby. Review of Resident #21's care plan revealed there was no documentation that Resident #21 preferred to be called Baby. Interview with the Administrator on 1/8/19 at 4:46 PM, in the Conference Room, the Administrator was asked if it was appropriate to call residents by pet names such as Momma, Baby, or Feeders. The Administrator stated, Absolutely not. 10. Observations in Resident #98's room on 1/9/19 at 9:50 AM, LPN #2 called Resident #98 by the names of Honey, Sweetie, and Baby multiple times while she administered medications. Interview with the Director of Nursing (DON) on 1/10/19 at 3:05 PM, in her office, the DON was asked if it was acceptable for a resident to be addressed as Sweetie, Baby, and Honey during medication administration. The DON stated, No, it's not acceptable. 11. Observations in the hallway by the 1 West Nurses Station on 1/9/18 at 7:38 AM, 10:30 AM, and 11:45 AM, revealed a posted sign which listed Feeders in rooms 101, 106, 108, 112, 124, 125, 131,132 and 138. Interview with the Administrator on 1/9/18 at 1:30 PM, at the 1 West Nurses Station, the Administrator was asked if it was appropriate to list residents as feeders and have it displayed in a hallway where any resident or visitor could see it. The Administrator stated, No.",2020-09-01
589,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,623,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer or discharge for 1 of 1 (Resident #74) sampled residents reviewed for transfer/discharge requirements. The findings include: Medical record review revealed Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. The progress notes dated 10/13/18 documented, .resident noted to be in respiratory distress .very weak and hard to arouse .Physician notified .called 911 for emergency transport .resident transferred to stretcher and taken from facility to ER (emergency room ) . The physician's orders [REDACTED].SEND TO (named) ER FOR EVAL (evaluation)/ TX (treatment) Review of the medical record revealed Resident #74 was admitted to the hospital and returned to facility on 10/19/18. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. Interview with the Administrator on 1/9/19 at 5:10 PM, at the 1 West Nurses Station, the Administrator was asked if the Ombudsman had been notified of Resident #74's transfer to the hospital. The Administrator stated, We don't send a transfer list to the Ombudsman, we only send the involuntary discharges to the Ombudsman.",2020-09-01
591,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,656,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 2 (Resident #55) residents were free from accident hazards by not following their interventions after the resident experienced a fall. The findings include: 1. The facility's undated Fall Prevention policy documented, .To identify residents 'at risk for falls' and utilize proactive approach to decrease the incidence of falls .Rehabilitation .Evaluate for appropriate positioning devices . 2. Medical record review revealed Resident #55 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 9, which indicated moderate cognitive impairment, required extensive staff assistance with transfers, and walking did not occur. The Care Plan dated 8/26/18 documented, .10/15/18 - eval (evaluation) for reacher use . Review of the Occurrence Report dated 10/15/18 revealed Resident #55 was not referred to therapy for screening after experiencing a fall without injury. Interview with the Physical Therapist (PT) #1 was asked for verification that Resident #55 had received a evaluation for a reacher. The PT #1 was unable to confirm that an evaluation had been performed. Interview with the Director of Nursing (DON) on 1/10/19 at 3:30 PM, in her office, the DON was asked if Resident #55 had a fall on 10/15/18, and the new interventions was to be evaluated for a reacher, should there have been an evaluation after the fall on 10/15/19 The DON stated, Yes.",2020-09-01
592,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,657,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident rights, medical record review, and interview, the facility failed to ensure each resident was involved in developing the care plan and making decisions about his or her care for 1 of23 (Resident #19) sampled residents reviewed for participation in care planning. The findings include: The facility's .Resident's Rights . documented, .Each resident has the right to be informed of, and participate in, his or her treatment, including .The right to participate in the development and implementation of his or her person-centered plan of care . Medical record review revealed Resident #19 was admitted to the faciity on 3/27/18 with [DIAGNOSES REDACTED]. Interview with Resident #19 on 1/7/19 at 4:42 PM, Resident #19 was asked if she was allowed to attend the care plan meetings. Resident #19 stated, No. Interview with the Social Worker on 1/9/19 at 4:52 PM, in her office, the Social Worker was asked if there was documentation that Resident #19 was asked to attend the care plan meetings. The Social Worker stated, I do not have a signed document saying her or her family were invited to a care plan meeting .We do not have proof of that.",2020-09-01
594,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,698,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a [MEDICAL TREATMENT] service agreement, policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 1 of 1 (Resident #63) residents reviewed for [MEDICAL TREATMENT]. The findings include: 1. The facility's LONG TERM CARE OUTPATIENT [MEDICAL TREATMENT] SERVICES COORDINATION AGREEMENT . documented, .The Long Term Care Facility shall provide for the interchange of information useful or necessary .Obligations of the [MEDICAL CONDITIONS] [MEDICAL TREATMENT] Unit .To provide to the Long Term Care Facility information on all aspects of the management of the [MEDICAL CONDITION] Resident's care . The facility's policy [MEDICAL TREATMENT] with a revised date of 4/4/18 documented, .Dietician will address .fluid restrictions .Residents will be issued a [MEDICAL TREATMENT] tool that will accompany them to [MEDICAL TREATMENT]. The primary nurse receiving the resident back from [MEDICAL TREATMENT] will review the [MEDICAL TREATMENT] tool for any pertinent information from [MEDICAL TREATMENT] . 3. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #63 received [MEDICAL TREATMENT]. The (MONTH) physician's orders [REDACTED].Every Day . [MEDICAL TREATMENT] MON, WED, FRI (Monday, Wednesday,Friday) . The Care Plan dated 6/15/17 documented, .(Named Resident #63) .Resident is currently on [MEDICAL TREATMENT] .Monitor/record fluid intake .as ordered by MD . Interview with Licensed Practical Nurse (LPN) #4 on 1/9/19 at 11:10 AM, at the 2nd floor West Nurses' Station, LPN #4 was asked where documentation of fluid restrictions would be located. LPN #4 stated, I don't. LPN #4 was asked what type of communication form goes with Resident #63 to [MEDICAL TREATMENT]. LPN #4 stated, Nothing .well we used to do that but, they ([MEDICAL TREATMENT] clinic) were not sending the form back so we stopped that .[MEDICAL TREATMENT] calls us every month or so and asked us for a copy of their medications . Interview with LPN #6 on 1/10/19 at 1:50 PM, in the Conference Room, LPN #6 was asked where documentation of fluid restrictions would be located. LPN #6 stated, We have no .documentation for fluid restrictions .",2020-09-01
595,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,790,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on consent for treatment, medical record review, observations and interviews the facility failed to provide dental services for 1 of 1 (Resident #87) residents reviewed for dental services. The findings include: 1. The facility's Special Care Dental .Consent consent for treatment dated 3/10/16 documented, .By signing below you authorize the provider indicated above to provide treatment .For dentistry . 2. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/9/17 documented, .(Named Resident #87) .DENTAL CARE IMPAIRMENT RISK .at high risk for further decline in dentition .refer for dental services as needed . Observations in Resident 87's room on 1/8/19 at 10:21 AM, revealed missing and broken teeth covered with plaque, a colored dark brown sticky film of undigested food particles. Interview with Resident #87's Power of Attorney on 1/8/19 at 10:21 AM, in Resident's #87's room, Resident #87's Power of Attorney was asked if Resident #87 had any dental issues and had she been seen by a dentist at the facility. Resident #86's Power of Attorney stated, .She has not seen the dentist since she was admitted here and it will be 3 years in (MONTH) . Interview with the Social Worker on 1/9/19 at 2:05 PM, at the 1 East Nurses Station, the Social Worker was asked about Resident #87's dental records. The Social Worker stated, She is being seen by vision but not by dental. The Social Worker was asked has Resident #87 been seen by a dentist since admission. The Social Worker stated, No .",2020-09-01
597,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,838,D,0,1,IXKF11,"Based on interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during day to day operations and emergencies. The findings included: The facility was unable to provide a facility assessment. Interview with the Administrator on 1/10/19 at 9:53 AM, in the Director of Nursing's office, the Administrator was asked to provide the facility assessment. The Administrator confirmed there was no facility assessment.",2020-09-01
598,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,880,D,0,1,IXKF11,"Based on policy review, medical record review, observation and interviews, the facility failed to ensure practices were maintained to prevent the spread of infection and cross-contamination when a resident's water pitcher was dirty for 3 of 3 (1/7/19, 1/8/19, and 1/9/19) days, when a nebulizer mask was not stored properly for 1 of 1 (Resident #57) residents reviewed for respiratory care, and 2 of 6 (Licensed Practical Nurse (LPN) #5 and 7) nurses did not perform hand hygiene during medication administration. The findings included: 1. Observations in Resident #302's room on 1/7/19 at 11:00 AM, 1/8/19 at 10:00 AM, and 1/9/18 at 7:38 AM, revealed a water pitcher with a brown to reddish substance smeared all over the top of the water pitcher. Interview with Licensed Practical Nurse (LPN) #6 on 1/9/19 at 2:20 PM, at Resident #302's bedside, LPN #6 was asked is it acceptable for the water pitcher to have dried brown substance on it. LPN #6 stated, No . Observations in Resident #57's room on 1/7/19 at 12:03 PM, revealed an uncovered nebulizer mask lying on the floor between the bed and the bedside table. Observations in Resident #57's room on 1/8/19 at 7:55 AM, revealed an uncovered nebulizer mask hanging from the bed side table. Observations in Resident #57's room on 1/08/19 at 3:32 PM, revealed an uncovered nebulizer mask lying on top of the bedside table. Observations in Resident #57's room on 1/9/18 at 8:35 AM, revealed an uncovered nebulizer mask hanging from nebulizer machine. Interview with the Director of Nursing (DON) on 1/9/19 at 2:50 PM, at the 1 West Nursing Station, the DON was asked if it was acceptable to have a nebulizer mask in the residents room uncovered. The DON stated, No ma'am .the mask should be covered and dated. 2. The facility's undated .Hand-hygiene . policy documented, .To prevent and to control the spread of infectious diseases .The purpose of this procedure is to provide guidelines .in the prevention of the transmission of infections . Observations in Resident #98's room on 1/9/19 at 8:45 AM, revealed LPN #5 failed to perform hand hygiene multiple times after glove removal during the preparation of medications. Observations in Resident #7's room on 1/9/19 at 5:05 PM, revealed LPN #7 failed to perform correct hand hygiene by turning off the water faucet with her bare hands during medication administration. Interview with the Administrator on 1/10/19 at 10:30 AM, in the Administrator's office, the Administrator was asked if was acceptable for staff to remove their gloves and not perform hand hygiene. The Administrator stated, No. The Administrator was asked if it was acceptable for staff to turn the water faucet off with their bare hands. The Administrator stated, No.",2020-09-01
599,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,583,D,0,1,G3SM11,"Based on policy review, observation, and interview, the facility failed to ensure privacy and interruptions by 2 staff members (Director of Nursing (DON ) and Dietary Aide #1) during the Resident Council meeting. The findings included: 1. The Resident Rights Policy and Procedure documented .ensure that every resident can exercise his or her rights without interference .from facility . 2. Observations in the dining room on 1/31/18 from 1:40 PM to 2:30 PM, during the Resident Council Meeting, revealed the DON and Dietary Aide #2 entered the dining room. The Resident Council meeting was stopped with each interruption and resumed when the staff members left. 3. Interview with Social Services Director on 1/31/18 at 4:50 PM, in the Social Service Office, the Social Services Director was asked who was responsible for making sure the Resident Council meetings were private and not interrupted. The Social Services Director stated, I put a sign up on one door and no one is allowed to enter during the meeting .but there were no signs put on all the entrances to the dining room, just one. The Social Services Director was asked if signs should be put on all the dining room doors to respect the privacy of the Resident Council meeting. The Social Services Director stated, Yes.",2020-09-01
600,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,584,D,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when an uncovered and unlabeled toothbrush and bed pan were found in 1 of 77 (room [ROOM NUMBER]A) resident rooms and the facility failed to maintain comfortable sound levels that did not interfere with the resident's hearing, privacy, and social interaction during 1 of 1 Resident Council meeting. The findings included: 1. Observations in room [ROOM NUMBER]A on 1/30/18 at 10:00 AM, revealed an unlabeled, uncovered toothbrush lying on the windowsill without a barrier. Interview with Certified Nursing Assistant (CNA) #1 on 1/30/18 at 10:05 AM, in room [ROOM NUMBER]A, CNA #1 was asked whether it was sanitary for the toothbrush to be lying open on the windowsill. CNA #1 stated,No . 2. Observations in room [ROOM NUMBER]A bathroom on 1/30/18 at 4:49 PM, revealed an uncovered and unlabeled bed pan on the trash can. Interview with CNA #2 on 1/30/18 at 5:29 PM, in room [ROOM NUMBER]A bathroom, CNA #2 was shown the bedpan that was uncovered and unlabeled lying on top of the trash can and was asked should the bed pan be on the trash can. CNA #2 stated, .no ma'am . Interview with the Director of Nursing (DON) on 1/31/18 at 1:16 PM, in the DON's office, the DON was asked how should a resident's bedpan be stored. The DON stated, It should be stored in a bag .rinsed and clean .should have the room number . The DON was asked should a bedpan be stored on the trash can uncovered or unlabeled. The DON stated, That would not be appropriate . The DON was asked where a resident's toothbrush should be stored. The DON stated, .should be rinsed and stored in the resident's mouth basin. The DON was asked is it acceptable for a resident's tooth brush to be left on a windowsill. The DON stated, No . 3. Observations in the dining room on 1/31/18 from 1:40 PM to 2:15 PM, during the Resident Council Meeting, revealed 16 overhead announcements that interrupted the Resident Council meeting. The meeting was stopped with each interruption and resumed when the overhead announcements were completed. Interview with the Resident Council members on 1/31/18 from 1:40 PM to 2:15 PM, in the dining room, Resident #30 stated, The intercom interruption happens all the time. Interview with the Administrator on 1/31/18 at 4:28 PM, in the hallway outside the Administrator's office, the Administrator confirmed the paging system should be checked for comfortable sound levels.",2020-09-01
601,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,689,D,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 1 of 77 (room [ROOM NUMBER]) resident rooms and unsecured chemicals were observed in 1 of 2 (200 hall) mop closets. The findings included: Observations in room [ROOM NUMBER] on 1/29/18 at 11:38 AM, 12:59 PM, and 3:26 PM, revealed an unlocked door with 2 spray cans of contact adhesive sitting on the floor to the right of the doorway, an unlocked maintenance cart inside the room, with a box cutter lying on top, 5 small open compartments along the front with screws present, a small saw like tool hanging on the right side of the cart, and a strip of wood with 15 nails, sharp side facing out, leaning against the wall to the left of the door. Observations in the 200 hallway on 1/29/18 at 11:39 AM, 1:00 PM, and 3:25 PM, revealed an unlocked mop closet with a bottle of disinfectant, a bottle of floor cleaner with no lid, a bottle of glass cleaner on a shelf along the right wall, a shelf on the floor inside the room with 2 bags of antimicrobial soap on the top shelf, a bottle of floor cleaner, and a bottle of disinfectant on the bottom shelf. Interview with Licensed Practical Nurse (LPN) #1 on 1/29/18 at 1:03 PM, at the 200 West nurses station, LPN #1 confirmed there were wandering residents in rooms 201, 203, 208 and 214. Interview with the Administrator on 1/29/18 at 4:24 PM, in the 200 hallway, the Administrator confirmed room [ROOM NUMBER] and the 200 hall mop closet should be locked.",2020-09-01
604,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,157,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions.",2020-09-01
606,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,226,D,1,0,DC3711,"**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 report an allegation of abuse timely to the supervisor/administrator/abuse coordinator for 1 resident (#3) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .All investigations will be conducted in a timely, thorough and objective manner . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review of the Initial Wound & Skin Record for Resident #3 dated 4/11/17 revealed .No bruises, marks or injuries noted on skin . Medical record review of a nurse's note dated 4/13/17 at 6:42 PM and written by the Director Of Nursing (DON) revealed .Late entry for 4/11/17. Resident was sitting in her room on 4/8/17 when another resident entered her room. Resident attempted to get him out of room and when she approached the resident, he slapped her in her face . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation revealed on 4/8/17 Resident #5 went into Resident #3's room and slapped Resident #3 on the face. Continued review of the facility investigation revealed an undated statement written by LPN #1 recounting the events of the incident on 4/8/17. Further review of the investigation revealed the occurrence report was not written until 4/11/17 by the DON. Interview with the Administrator and the DON on 5/10/17 at 3:55 PM in the conference room revealed they were not made aware of the incident involving Resident #5 hitting Resident #3 until 4/11/17. Further interview revealed it was the expectation of the administrator, who was also the abuse coordinator, for all allegations of abuse to be reported immediately to the supervisor and/or abuse coordinator. Continued interview revealed the Administrator confirmed LPN #1 failed to report the incident immediately to the supervisor and/or abuse coordinator.",2020-09-01
607,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,279,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 resident (#4) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .An individualized comprehensive care plan that included measureable objectives .to meet the resident's medical, nursing, mental and psychological needs is developed for each resident Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 2/13/17 revealed .BEHAVIORS: (Resident #4) displays disruptive behaviors with yelling out at times . Further review revealed there was no goal for the care plan. Interview with the Minimum Data Set (MDS) Coordinator on 5/9/17 at 2:13 PM in her office revealed she did not list a goal for the Behavior Care Plan for Resident #4 because she was unsure at the time of the reason for the yelling and stated she was unsure if it was psych (psychiatric) or pain or something else. Interview with the Director of Nursing on 5/10/17 at 11:00 AM in the MDS office, with the MDS Coordinator present revealed there should have been a goal even if the reason for the behaviors was uncertain. Further interview with the DON confirmed it was inappropriate and the facility had failed to develop a comprehensive care plan for Resident #4.",2020-09-01
608,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,280,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete a care plan within 7 days after the completion of the comprehensive assessment and failed to revise a care plan for behaviors involving hallucinations for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) .Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of the care plans . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #1's Brief Interview for Mental Status was 12/15 indicating she was moderately cognitively impaired; had no mood, psychotic episodes or behaviors; she could hear adequately, and she could make herself understood and understood others. Medical record review revealed the care plan following the comprehensive MDS was dated 3/3/17, exceeding the 7 days after the assessment. Medical record review of the nursing notes revealed on 3/9/17 Resident #1 had experienced .hallucinations . Further review of nursing notes revealed the resident was seeing 1 or more children in her room or in her bed. Medical record review of the Social Service progress note dated 3/31/17 revealed .Res (Resident) continues to verbalize hallucinations according to nursing staff . Interview with the MDS Coordinator on 5/8/17 at 4:15 PM in the conference room confirmed Resident #1 had been experiencing visual hallucinations since 3/9/17 and the facility failed to revise the care plan until 4/3/17. Interview with the MDS Coordinator on 5/9/17 at 3:15 PM in the MDS office confirmed the MDS was completed on 2/8/17 and the facility failed to complete the care plan within 7 days of the MDS. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:05 PM in the Administrator's office, confirmed the facility failed to complete a care plan timely after a comprehensive assessment per facility policy. Further interview confirmed the facility failed to revise the care plan timely to address the hallucination per facility policy.",2020-09-01
609,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,281,D,1,0,DC3711,"**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 a physician order [REDACTED]. The findings included: Review of facility policy, Medication and Treatment Orders, revised 2/2014 revealed .Orders for medications and treatments will be consistent with principles of safe and effective order writing .shall be administered only upon the written order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].DC (discontinue) zinc oxide cream (ointment for skin treatment) to buttock and groin q (every) shift and as needed . Further review revealed no physician signed telephone order or physician signed computerized order to initiate the the zinc oxide treatment. Medical record review of the 2/2017 and 3/2017 Treatment Administration Records revealed the zinc oxide treatment was administered from 2/15/17 to 3/13/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/10/17 at 9:30 AM at 1 East nursing station confirmed she had written the 3/13/17 discontinuation of zinc oxide order. LPN #2 reviewed the telephone and computerized physician orders [REDACTED]. Interview with the Administrator on 5/10/17 at 10:45 AM in the conference room confirmed the facility failed to follow the facility policy to only administer medications and treatments after a physician order [REDACTED].",2020-09-01
610,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,323,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, facility investigation review, and interview the facility failed to prevent an altercation for 2 residents (#3, #4) of 5 residents reviewed. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents.",2020-09-01
613,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-07-11,609,D,1,0,CCNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, it was determined the facility failed to report allegations of abuse within 2 hours for 2 of 2 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect and Exploitation policy documented, .Report allegations or suspected abuse, neglect or exploitation immediately to State Agencies . Medical record review revealed Resident #1 was admitted to facility 6/20/18 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment for decision making. Interview with Resident #1 on 7/9/19 at 11:00 AM, in the Social Service office, Resident #1 stated, He hit me in the back of the head two times so I let go of walker and his wheelchair fell backwards into the grass . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment for decision making. Review of the Occurrence Report dated 6/20/19 documented, .(Resident #2) was push (pushed) by another resident (#1) causing wheel (wheelchair) to go off pavement cause (causing) him (Resident #2) to fall . Interview with the Director of Nursing (DON) on 7/11/19 at 1:00 PM, in her office, the DON confirmed the date of the incident was 6/20/19 and was not reported until 6/22/19. The DON was asked if the alleged abuse was reported timely. The DON stated, Probably not.",2020-09-01
616,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,690,D,0,1,H2CG11,"**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 care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 1 (Resident #207) sampled residents reviewed with indwelling urinary catheters. The findings include: 1. The facility's Catheter Care, Urinary policy with a revision date of (MONTH) 2014, documented, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . 2. Medical record review revealed Resident #207 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley Catheter . Observations in Resident #207's room on 11/17/19 at 4:31 PM and 11/18/19 at 8:26 AM, revealed Resident #207 was lying in the bed, with the indwelling urinary catheter drainage bag lying on the floor. Interview with the Director of Nursing (DON) on 11/19/19 at 3:50 PM, in the DON Office, the DON was asked if an indwelling urinary catheter drainage bag should be lying on the floor. The DON stated, No.",2020-09-01
617,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,759,D,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses administered medications with an error rate of less than 5 percent. A total of 4 errors were observed out of 31 opportunities, resulting in an error rate of 12XXX 581 percent (%). The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .Inhaled Medications .Check Medication Record for order .If another puff of the same or different medication is required, wait 1-2 minutes .then repeat . 2. The facility's Administering Medications policy with a revision date of (MONTH) 2012, documented, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication right dosage, right time and right method (route) of administration before giving the medication . 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].D/C (discontinue) [MEDICATION NAME] 5mg q (every) 12 hours PRN (as needed) . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 mg-325 mg .give 1 tablet by oral route every 6 hours as needed . The physician's orders [REDACTED].potassium chloride ER (extended release) 20 mEq (milliequivalents) tablet .give 2 tablets (40 meq) by oral route once daily with food . The physician's orders [REDACTED].[MEDICATION NAME] 160 mcg (micrograms)-4.5 mcg/actuation .inhale 1 puff by inhalation route 2 times per day . The physician's orders [REDACTED].[MEDICATION NAME] .90 mcg/actuation aerosol inhaler .inhale 1 puff (90 mcg) by inhalation route 3 times per day . Observations in Resident #27's room on 11/18/19 at 10:53 AM, revealed LPN #3 administered potassium chloride 20 mEq 1 tablet by mouth and [MEDICATION NAME] 5 mg 1 tablet by mouth. The administration of potassium Chloride 20 mEq instead of 40 mEq resulted in medication error #1. The administration of [MEDICATION NAME] 5 mg instead of the [MEDICATION NAME] 5 mg-325 mg resulted in medication error #2. Observations in Resident #27's room on 11/18/19 at 10:53 AM, revealed LPN #3 administered [MEDICATION NAME] 2 consecutive puffs to Resident #27. LPN #3 then immediately administered [MEDICATION NAME] 160/4.5 meq 2 consecutive puffs to Resident #27 on 11/18/19 at 10:54 AM. The administration of the incorrect number of puffs of [MEDICATION NAME] and [MEDICATION NAME] and the failure to wait 1 to 2 minutes between puffs resulted in medication error #3 and #4. Interview with LPN #2 (LPN #3 was unavailable) on 11/18/19 at 11:56 AM, at the 1 West Nurses' Station, LPN #2 confirmed Resident #27 should have received potassium chloride 20 mEq 2 tablets by mouth instead of 1 tablet. LPN #2 was asked if Resident #27 should have received an [MEDICATION NAME] 5 mg tablet, or a [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) tablet. LPN #2 stated, They DC'd [MEDICATION NAME] 5 (mg) on 10/29 (10/29/19). LPN #2 confirmed according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 11/19/19 at 5:13 PM, in the DON Office, the DON was asked how long the nurse should wait between administration of 2 different inhalers. The DON stated, Two minutes .",2020-09-01
618,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,761,D,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were not stored past their expiration dates, medications were dated when opened, medication carts were kept secure, and medications were stored properly in 4 of 13 (1 East Treatment Cart, 2 West Medication Room, 2 West Medication Cart, and 1 West Medication Cart) medication storage areas. The findings include: 1. The facility's Storage of Medication policy with a revision date of (MONTH) 2007 documented, .The facility shall not use .outdated or deteriorated drugs or biologicals . The facility's Administering Medications policy with a revision date of (MONTH) 2012 documented, .During administration of medication, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide .It may be kept in the doorway of the resident's room .with open drawers facing inward and all other sides closed .No medications are kept on top of the cart .The cart must be clearly visible to the personnel administering medications, and all outward side must be inaccessible to residents or to others passing buy . 2. Observations on the 1 East hall on 11/17/19 at 11:05 AM, 11:29 AM, and 11:45 AM, revealed the 1 East Treatment Cart was unsecured and unattended. Interview with Registered Nurse (RN) #1 at the 1 East Nurses' Station on 11/18/19 at 11:45 AM, RN #1 was asked if the treatment cart should be locked. RN #1 stated, Yes . 3. Observations in the 2 West Medication Room on 11/17/19 at 12:32 PM, revealed 1 opened bottle of [MEDICATION NAME] vaccine with no open date and 1 opened bottle of [MEDICATION NAME] vaccine with an open date of 8/1/19. Interview with Licensed Practical Nurse (LPN) #1 on 11/17/19 at 12:32 PM, in the 2 West Medication Room, LPN #1 was asked how long the [MEDICATION NAME] vaccine was good for after opening. LPN #1 stated, 60 days. LPN #1 was asked if the medication should be dated when opened. LPN #1 stated, Yes. Interview with the Director of Nursing (DON) on 11/19/19 at 6:23 PM, in the Conference Room, the DON was asked if she would expect to have open medications stored beyond the expiration date, or opened and undated medications stored in the medication storage areas. The DON stated, No. 4. Observations at the 2 West Medication Cart on 11/18/19 at 9:31 AM, revealed RN #2 pulled medications from the medication cart, entered Resident #355's room, and left the medication cart unsecured and unattended. Interview with RN #2 on 11/18/19 at 9:37 AM, outside of Resident #355's room, RN #2 was asked if she could see the 2 West Medication Cart from Resident #355's room. RN #2 stated, No . RN #2 was asked should the medication cart be left unsecured and unattended. RN #2 stated, No. 5. Observations at the 1 West Medication Cart on 11/18/19 at 10:51 AM, revealed LPN #3 prepared the medications for administration, and entered Resident #27's room. LPN #3 left a [MEDICATION NAME] (a narcotic medication patch) unsecured and unattended on top of the medication cart. Observations at the 1 West Medication Cart on 11/18/19 at 10:55 AM, revealed LPN #3 entered Resident #27's room to administer the [MEDICATION NAME], and left a [MEDICATION NAME] and [MEDICATION NAME] inhaler unsecured and unattended on top of the medication cart. Interview with LPN #3 on 11/18/19 at 10:55 AM, at the 1 West Medication Cart, LPN #3 was asked if she should have left the [MEDICATION NAME] unsecured and unattended on top of the medication cart. LPN stated, No. Interview with LPN #3 on 11/18/19 at 10:59 AM, at the 1 West Medication Cart, LPN #3 was asked if she should have left the inhalers unsecured and unattended on top of the medication cart. LPN #3 stated, No. Interview with the Director of Nursing (DON) on 11/19/19 at 3:50 PM, in the DON Office, the DON was asked if she expected nurses to keep the medications secured. The DON stated, Yes.",2020-09-01
619,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,924,D,0,1,H2CG11,"Based on observation and interview, the facility failed to maintain a safe environment when the handrails in the hallway were loose and hanging off the wall for 1 of 8 (1 West Hall) hallways. The findings include: Observations in the 1 West Hall on 11/17/19 at 10:38 AM, revealed the handrails were loose and broken between the resident common bathrooms and on the left and right side of the 1 West Nurses' Station. Interview with the Administrator on 11/19/19 at 11:51 AM, in the Administrator Office, the Administrator was asked if the handrails should be firmly attached to the wall. The Administrator confirmed the handrails should be firmly attached to the wall.",2020-09-01
622,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,812,D,0,1,C2ER11,"Based on review of facility policy, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working on the tray line without wearing a beard net on 1 of 3 observations. Findings include: Review of facility policy, General Sanitation of Kitchen dated 2013 revealed .beard nets are required when facial hair is visible . Observation of the noon meal on 7/9/18 at 11:35 AM in the dietary department revealed one male dietary employee working on the residents tray line with visible facial hair not wearing a beard net. Interview with the Dietary Manager on 7/9/18 at 11:36 AM in the dietary department confirmed the male employee failed to wear a beard net to cover facial hair while working on the tray line.",2020-09-01
623,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,880,D,1,1,C2ER11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated 10/1/07 revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].change PICC line dressing 24-48 hours after insertion of line if dressing is soiled and then every 7 days . Observation on 7/10/18 at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with a date of 6/20/18. Observation and interview with the Unit Manager on 7/10/18 at 9:52 AM in Resident #1's room confirmed the transparent dressing was dated 6/20/18 to Resident #1's PICC line. Further interview revealed the Unit Manger stated I see it and nodded her head in agreement that the facility failed to change the soiled dressing weekly as ordered.",2020-09-01
626,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,558,D,0,1,GH7811,"Based on facility policy review, observation, and interview, the facility failed to ensure call lights were within reach for 10 residents (#3, #27, #35, #37, #43, #44, #65, #68, #71, #80) of 93 residents reviewed. The findings included: Review of facility policy, Nurse Call System, dated 9/1/14, revealed .Each cord needs to be visible and reachable by the resident to which it operates for . Observation on 12/18/17 at 8:00 AM in Resident #68's room revealed his call light was clipped to a pillow in the floor and the cord was draped across his neck and out of reach. Observation on 12/18/17 at 8:05 AM in Resident #3's room revealed her call light was clipped to the left side rail. Resident #3 was unable to use her left hand and fingers, was unable to push the call light, and could not reach the call light with her right hand. Observation on 12/18/17 at 8:07 AM in Resident #43's room revealed her call light was clipped to the right side rail. Resident #43 was unable to use her right hand and could not reach the call light with her left hand. Observation on 12/18/17 at 8:07 AM in Resident #71's room revealed her call light was on the floor and out of her reach. Observation on 12/18/17 at 9:25 AM in Resident #27's room revealed she had a push pad call light and it was out of reach on the bedside table. Observation on 12/18/17 at 9:27 AM in Resident #37's room revealed her call light was clipped to the top of the back of the pillow which was under her head and was out of reach of the resident. Observation on 12/18/17 at 9:28 AM in Resident #35's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 9:29 AM in Resident #65's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 9:31 AM in Resident #80's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 12:50 PM in Resident #44's room revealed the resident was lying in bed and the call light was hanging on the wall on a thumb tack out of reach of the resident. Observation and interview with Licensed Practical Nurse (LPN) #3 on 12/18/17 at 9:20 AM at the North Nurse Station confirmed the facility failed to keep the call lights within reach for Resident #3, #43, #68, and #71. Observation and interview with LPN #1 on 12/18/17 at 10:20 AM on the 300 Hall confirmed the facility failed to keep the call lights within reach for Resident #27, #35, #37, #65, and #80. Observation and interview with LPN #2 on 12/18/17 at 12:52 PM in the hallway near Resident #44's room confirmed the facility failed to keep the call light within reach for Resident #44.",2020-09-01
629,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,657,D,0,1,GH7811,"**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 2 residents (#45, #68) of 19 residents reviewed for care plans. The findings included: Medical record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL TREATMENT] Communication Record dated 8/1/17 revealed .Shunt Site: Location: R (right) arm . Medical record review of the Care Plan, with problem onset dated 10/16/15, and last updated 11/27/17, revealed .requires [MEDICAL TREATMENT] .ACCESS Site: Left Arm . Interview with Licensed Practical Nurse (LPN) #1 on 12/19/17 at 3:25 PM at the South Nurses Station revealed Resident #45's [MEDICAL TREATMENT] shunt was now in his right arm and the location was changed several months ago. Interview with Minimum Data Set Coordinator on 12/19/17 at 3:40 PM in his office revealed the care plan does say left. Continued interview confirmed the facility failed to revise the Care Plan to reflect the correct positioning of the [MEDICAL TREATMENT] shunt for Resident #45. Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Care Plan updated on 11/1/17 revealed .readmit 11/1/17 resident at risk for altered integument (skin) due to impaired mobility . Further review revealed the Care Plan was not revised to reflect the [MEDICATION NAME] Lumbar Spinal brace until 11/14/17 when pressure ulcer on armpit was found. Medical record review of the Care Plan Conference Summary dated 11/15/17 revealed .Nursing discussed the wounds from the brace (back brace) Resident is taking the brace off himself, son reports to take brace off Resident and leave him in bed . Interview with LPN #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurse's Station revealed .He came back from the hospital with the brace on and on bed rest. He had a big decline after the last fall . Further interview with LPN #3 confirmed the facility failed to revise the Care Plan dated 11/1/17 to reflect the [MEDICATION NAME] Lumbar Spine Brace.",2020-09-01
632,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,688,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to utilize devices to improve range of motion for 1 resident (#74) of 16 residents reviewed. The findings included: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #74 was severely impaired cognitively. Continued review of the MDS revealed Resident #74 was dependent on 1 person for transfers and bathing; required extensive assistance of 1 person for dressing, grooming, and eating; had impairment of 1 upper extremity and both lower extremities for range of motion. Further review revealed Resident #74 was always incontinent of bowel and had an indwelling catheter. Medical record review of physician's orders [REDACTED].Put on left elbow splint and left hand splint at beginning of 7-3 (7 AM - 3 PM) shift. Take off left elbow splint and left hand splint at end of shift 7-3 (7 AM - 3 PM). Wear time no more than 8 hours . Observation on 12/18/17 at 9:15 AM revealed Resident #74 was lying in bed. Observation of the resident's left arm revealed no splint in place on the hand or elbow. Observation on 12/19/17 at 10:00 AM revealed Resident #74 lying in bed with no splint on the left hand or left elbow. Interview with Licensed Practical Nurse #2 on 12/19/17 at 10:07 AM at the 200 Hall Nurses Station confirmed Resident #74 was ordered to have a left hand and elbow splint on during the 7:00 AM - 3:00 PM shift and the facility failed to apply the splint as ordered.",2020-09-01
634,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,732,D,0,1,GH7811,"Based on observation and interview, the facility failed to post the current staffing for 1 of 3 days. The findings included: Observation of the posted staffing on 12/20/17 at 11:45 AM revealed the posting was dated 12/18/17. Interview with the Administrator on 12/20/17 at 11:55 AM in the Administrator's office confirmed the posted staffing was the incorrect date.",2020-09-01
635,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,758,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete behavior monitoring for 1 resident (#81) of 5 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #81 received antipsychotic medication during the assessment look-back period. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (antipsychotic) 5MG (milligrams) BY MOUTH TWICE DAILY . Continued review revealed a Physician order [REDACTED].Discontinue [MEDICATION NAME] 5mg in AM (morning) Continue [MEDICATION NAME] 5mg at HS (bedtime). [MEDICATION NAME] 2.5mg 1 by mouth daily in AM . Further review revealed a Physician order [REDACTED].Decrease [MEDICATION NAME] to 2.5mg qhs (at bedtime) . Medical record review of the (MONTH) (YEAR)-December (YEAR) Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) through (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing on 12/20/17 at 9:30 AM in her office confirmed the facility failed to complete behavior monitoring for Resident #81 who was administered antipsychotic medication.",2020-09-01
636,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,761,D,0,1,GH7811,"Based on facility policy review, observation, and interview the facility failed to lock 1 of 5 medication carts. The findings included: Review of facility policy, Medication Storage in the Facility, undated, revealed .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . Observation on 12/20/17 from 11:45 AM to 11:50 AM in the secure unit common area revealed the 500 hall medication cart was not locked and no nurse was in view of the cart. There were no medications or residents in sight at time of occurrence. Observation and interview with the Director of Nursing on 12/20/17 at 11:51 AM in the secure unit common area at the 500 Medication Cart confirmed there was no nurse in sight of the cart and the facility failed to keep the 500 hall medication cart locked when not attended by the nurse in charge.",2020-09-01
638,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,919,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observation, and interview, the facility failed to ensure call lights were functioning properly in 7 of 55 resident rooms and in 6 of 55 resident bathrooms on 2 of 5 halls. The findings included: Review of the facility policy, Nurse Call System, dated 9/1/14, revealed .Monthly the Nurse Call system should be checked for proper function for the following .Each call cord should be exercised to ensure that it activates the light in the corridor and the annunciation panel at the nurse's station .Any component that does not function should be repaired as soon as practically feasible . Observation of the 300 hall rooms revealed the following: Observation on 12/18/17 at 9:40 AM in room [ROOM NUMBER] revealed a resident was sitting in bed and holding the call light in her left hand. The call light was plugged into the wall however, the cord was severed near the plug and therefore was not functioning. Interview with Licensed Practical Nurse (LPN) #1 on 12/18/17 at 10:20 AM on the 300 Hall confirmed the facility failed to maintain a functioning call light for the resident in room [ROOM NUMBER]. Observation of the 500 hall revealed the following: Observation on 12/18/17 from 10:20 AM to 10:25 AM revealed the call lights in rooms 504, 508, 509, 511, 512, and 513 were not functioning. Interview with CNA #1 on 12/18/17 at 10:27 PM on the 500 hall, this surveyor asked CNA #1 .How do you know if a resident needs help? . CNA stated .We have somebody on the floor walking up and down the hall . Interview and observation with LPN #2 on 12/18/17 between 12:40 PM and 12:52 PM confirmed the bathroom call lights in rooms 502, 504, 509, 510, 512, and 513 were not functioning and the call lights in rooms 504, 508, 509, 511, 512, and 513 were not functioning. Interview with the Maintenance Director on 12/18/17 at 3:15 PM at the south nurse station confirmed the facility failed to maintain functioning call lights for rooms 504, 508, 509, 511, 512, and 513 and for the bathrooms in rooms 504, 508, 509, 511, 512, and 513. Interview with the Maintenance Director on 12/20/17 at 3:00 PM in the Nurse Educator Office confirmed the Maintenance Director worked only a couple of months at the facility and did not know how to operate the work order system. Maintenace Director stated . he checks the call lights monthly but did not document the rooms he checked .",2020-09-01
639,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,550,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to treat 1 of 5 residents (Resident #391) who required an indwelling urinary catheter with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover, and failed to treat 4 of 17 residents with dignity who were referred to as feeders during the breakfast tray pass on 2/25/2020. The findings include: Review of the medical record, showed Resident #391 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#391, dated 2/24/2020, showed .16F (size of catheter) 10 ml (milliliter) catheter . Review of Resident #391's Care Plan dated 2/24/2020, showed .Cover drain bag with privacy bag/cover . Observation of the resident's room on 2/24/2020 at 9:22 AM, and 12:25 PM, showed Resident #391's indwelling urinary catheter bag was placed on the right side of the bed facing the door without a privacy cover. During an observation and interview conducted on 2/24/2020 at 1:22 PM, in the resident's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #391's indwelling urinary catheter bag was not placed in a privacy cover. During an interview conducted on 2/24/2020 at 4:14 PM, the Director of Nursing (DON) stated that her expectations were for the urinary catheter bags to be placed in a privacy cover at all times. Review of the medical record, showed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #14 dated 12/5/2019, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment for Resident #62 dated 1/31/2020, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS for Resident #64 dated 1/31/2020, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], showed the resident required extensive assistance of 1 person with eating. Observation of staff passing the breakfast meal trays on the 300 hallway on 2/25/2020 at 7:53 AM LPN #2 stated, The only trays left on the cart are for the feeders. During an interview conducted on 2/25/2020 at 7:55 AM, LPN #2 confirmed she referred to the residents who required assistance with dining as feeders. During an interview conducted on 2/25/2020 at 8:01 AM, the DON confirmed any resident who required assistance with meals were to be referred to as assisted diners not feeders.",2020-09-01
640,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,558,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, medical record review, observation, and interview the facility failed to have a call light in reach for 1 of 41 residents (Resident #27) reviewed for call light placement. The findings include: Review of the facility documentation, Call Light, Use Of, showed, .When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light .Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand . Review of the medical record, showed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Observation in the resident's room on 2/25/2020 at 9:12 AM, showed the call light was behind the chest of drawers located on the right side of the resident. During an observation and interview conducted on 2/25/2020 at 9:25 AM, with Licensed Practical Nurse (LPN) confirmed the call light was behind the chest of drawers and not in reach for Resident #27. During an interview conducted on 2/25/2020 at 2:40 PM, with the Director of Nursing (DON) confirmed the call was to be in reach for Resident #27 on the right side at all times.",2020-09-01
641,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,600,D,1,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to prevent abuse for 1 of 2 residents (Resident #42) involved in a resident to resident altercation. The findings include: Review of the facility policy, Abuse, dated June 2018, showed, .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing of the center. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE], with readmission on 6/7/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BI[CONDITION]) score of 11 indicating moderate cognitive impairment. Further review showed Resident #4 had verbal behavior symptoms directed toward others. Review of the medical record, showed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #42 was rarely/never understood. Further review showed the resident had no mood or behavioral symptoms. Review of the facility investigation dated 2/18/2020, showed a witnessed physical altercation between Resident #4 and Resident #42 in the Activity room while waiting for the activity to begin. Further review showed Resident #4 grabbed Resident #42's wrist, slapped and kicked her. During an interview conducted on 2/25/2020 at 7:30 AM, the Activity Director confirmed Resident #4 and Resident #42 had a physical altercation. Further interview she stated, When I walked into the Activity room I saw (named Resident #4) holding (named Resident #42's) wrist. I asked (named Resident #4) to let go of (named Resident #42) and before I could separate them (named Resident #4) slapped and kicked (named Resident #42). During an interview conducted on 2/26/2020 at 2:10 PM, the Administrator confirmed Resident #4 and Resident #42 had a physical altercation on 2/18/2020.",2020-09-01
642,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,641,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to capture Hospice Services on the Quarterly Minimum Data Set (MDS) assessment for 1 of 4 residents (Resident #19) who received hospice services. The findings include: Review of the medical record, showed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Under the services of (named Hospice) . Review of the Quarterly MDS assessment dated [DATE], showed Hospices were not captured for Resident #19. During an interview conducted on 2/26/2020 at 3:25 PM, the MDS Coordinator confirmed Resident #19's Quarterly MDS dated [DATE] did not reflect hospice services.",2020-09-01
643,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,677,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 1 of 41 residents (Resident #31) had clean and groomed fingernails. The findings include: Review of the medical record, showed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #31 was dependent on staff for bathing and required extensive assistance of 2 staff for personal hygiene. Review of the comprehensive care plan dated 10/15/2018, showed Resident #31 required assistance with bathing. Observations of the resident's room on 2/24/2020 at 9:17 AM and 11:13 AM, showed Resident #31 had brown debris under his fingernails on both hands. Observation of the resident's room on 2/24/2020 at 12:22 PM, showed Resident #31 lying in bed eating his lunch. Continued observation showed the resident had brown debris under his fingernails on both hands. During an observation and interview conducted on 2/24/2020 at 12:43 PM, Certified Nursing Assistant (CNA) #1 confirmed she was assigned to care for the resident on that day; she stated I gave him a bath this morning and cleaned his fingernails. During continued interview CNA #1 looked at the resident's hands and confirmed the resident had brown debris underneath his fingernails on both hands, she stated, I guess I didn't clean them as well as I should have. During an observation and Interview conducted on 2/24/2020 at 1:07 PM Licensed Practical Nurse #1 confirmed the resident had brown debris underneath his fingernails on both hands. During an interview conducted on 2/24/2020 at 5:14 PM, the Director of Nursing confirmed her expectation was for the residents' nails to be cleaned with bathing and when they were visibly dirty.",2020-09-01
644,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,684,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to implement physician's orders for 1 of 41 residents (Resident #88) reviewed for physician orders. The findings include: Review of the medical record, showed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Order Report dated 2/26/2020, showed, .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), Free T4 (Free [MEDICATION NAME]) with TSH ([MEDICAL CONDITION] Stimulating Hormone), Hepatic Panel, Lipid Panel and HgbA1C (Glycated Hemoglobin) every 6 months, (MARCH and SEPTEMBER) . Review of the medical record, showed there was no CBC, BMP, T4 with TSH or HgbA1C obtained for the month of (MONTH) 2019 or (MONTH) 2019. During an interview conducted on 2/26/2020 at 10:40 AM, the Director of Nursing confirmed Resident #88 did not have a CBC, BMP, Free T4 with TSH, or HgbA1C obtained in (MONTH) or (MONTH) 2019.",2020-09-01
645,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,695,D,0,1,T07H11,"**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 label and date oxygen tubing and store nebulizer tubing in a safe and sanitary manner for 2 of 18 residents (Residents #27 and #390) receiving respiratory treatments. The findings include: Review of the facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated (MONTH) 2011, showed, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .change the oxygen cannula and tubing every seven (7) days, or as needed .Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol: Store the circuit in plastic bag, marked with date and resident's name, between uses . Review of the medical record, showed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the physician order dated 2/26/2020, showed, .Oxygen at bedtime at 2 LPM (litters per minute) to use when in bed . Review of the medical record, showed Resident #390 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Orders dated 2/24/2020, showed .change oxygen tubing and clean 02 concentrator every Sunday night 11-7 shift .[MEDICATION NAME] (a medication to treat wheezing and shortness of breath) Nebulization Solution (2.5 MG/3ML (milligram/milliliter)) 0.083% 1 inhalation orally via nebulizer every 4 hours as needed for wheezing . Observation in the resident's room on 2/24/2020 at 9:41 AM, showed Resident #27's oxygen tubing was not dated. Observation in the resident's room on 2/24/2020 at 9:46 AM and 12:38 PM, showed Resident #390's oxygen and nebulizer tubing was not dated. Continued observation showed the nebulizer tubing and mouthpiece was placed on the nebulizer machine not stored in a bag. During an observation and interview conducted on 2/24/2020 at 1:12 PM, Licensed Practical Nurse #1 confirmed Resident #390's oxygen tubing and nebulizer mouthpiece was not dated or stored in a bag. During an interview conducted on 2/26/2020 at 4:50 PM, the Assistant Director of Nursing (ADON) confirmed the oxygen tubing and equipment was to be changed and dated every Sunday night. During an interview conducted on 2/24/2020 at 5:14 PM, the Director of Nursing confirmed her expectations were for the oxygen tubing, nebulizer tubing and mouthpiece to be dated and stored in a bag when not in use.",2020-09-01
648,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,550,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide 1 (#16) of 5 residents with dignity during the noon meal on 3/4/19 related to Certified Nurse Aide (CNA) standing while assisting Resident #16 with the meal. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/4/19 at 12:04 PM in the 300 hallway revealed CNA #1 was standing while assisting Resident #16 with the meal. Interview with CNA #1 on 3/4/19 at 12:05 PM in the 300 hallway confirmed she was standing while assisting Resident #16 with the noon meal. Interview with the Director of Nursing on 3/6/19 at 9:26 AM in the Conference Room confirmed staff were to sit while assisting residents with meals.",2020-09-01
649,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,644,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to perform a level 2 Preadmission Screening and Resident Review (PASARR) for 1 resident (#27) of 11 residents receiving antipsychotics. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #27 was diagnosed with [REDACTED]. Medical record review revealed Resident #27 did not have a level 2 PASARR. Medical record review of Resident #27's Annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Continued review revealed the resident had a [DIAGNOSES REDACTED]. Interview with the Regional Nurse Consultant (RNC) on 3/5/19 at 12:45 PM in the Director of Nurse's (DON) office confirmed Resident #27 was not screened for a level 2 PASARR after being diagnosed with [REDACTED]. Interview with the DON on 3/6/19 at 7:45 AM in her office confirmed when a resident was diagnosed with [REDACTED]. Interview with the RNC on 3/6/19 at 8:25 AM in the conference room confirmed Resident #27 did not have a level 2 PASARR screening. Continued interview confirmed I agree the [DIAGNOSES REDACTED].#27) and I don't have one to show you.",2020-09-01
650,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,695,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility's performance skill checklist oxygen delivery form review, medical record review, observation and interview, the facility failed to properly store oxygen tubing, nebulizer mask and tubing for 1 resident (#62) of 14 residents reviewed receiving respiratory treatments. The findings include: Review of the undated facility policy, Using Small Volume Nebulizers, revealed .reassemble the clean nebulizer parts and store them in a small bag between treatments . Review of facility's performance skill checklist oxygen delivery form revealed .attach oxygen delivery device to oxygen tubing .place in a bag .Keep off floor when not in use . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #62's Annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident received oxygen therapy. Medical record review of Resident #62's Order Review Report revealed .[MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]-medication used to prevent the worsening of [MEDICAL CONDITION]) Neb (nebulizer) 1 vial inhale orally every 6 hours as needed for wheezing related to shortness of breath (8/1/18) . Observation on 3/4/19 at 9:27 AM and at 3:39 PM revealed Resident #62 in her room in bed with oxygen in place by nasal cannula. Continued observation revealed the resident had a nebulizer treatment machine with an uncovered mask not stored in a bag sitting on the machine. Continued observation revealed a portable oxygen tank on the resident's wheelchair with the tubing exposed and not stored in a bag. Observation and interview on 3/4/19 at 3:44 PM, with Licensed Practical Nurse #1 present, confirmed Resident #62's nebulizer mask and tubing and the resident's oxygen tubing were not stored properly in a plastic bag. Continued interview revealed .when the resident finishes the treatment the masks are washed and dried and then placed in a plastic bag on the nebulizer machine and the oxygen tubing is also stored in a bag or thrown away if not in use . Interview with the Director of Nursing on 3/6/19 at 7:45 AM in her office confirmed nebulizer tubing, masks and oxygen tubing were to be stored in a bag when not in use.",2020-09-01
651,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,755,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Pharmacy contract review, observation and interview, the pharmacy services failed to ensure medications and biologicals were stored and labeled according to current professional standards of practice for 3 of 5 medication carts. The findings include: Review of the Pharmacy contract titled Pharmacy Services Agreement, dated (MONTH) 21, (YEAR), revealed .Services include disposing of outdated and disposing of or restocking of discontinued non-controlled medications provided by the pharmacy . Observation of the 100 Hall medication cart on 3/5/19 with Licensed Practical Nurse (LPN) #1 at 1:11 PM revealed [MEDICATION NAME] 1% (percent) cream (medicated cream used to treat fungal infections) opened and not dated; Iron Supplement [MEDICATION NAME] (liquid medication for low hemoglobin/decreased red blood cells) 220 mg/tsp (milligram per teaspoon) multiple dose 16 oz. (ounce) bottle opened and expired 2/2019. Observation of the 200 Hall medication cart on 3/5/19 with LPN #5 at 4:22 PM revealed 1 vial of [MEDICATION NAME] R Insulin (injectable medication for Diabetes Mellitus), the vial was opened on 2/1/19 and expired on 2/28/19; 2 [MEDICATION NAME] opened, not dated and not stored inside the protective foil package (special packaging to protect the medication from light and moisture); [MEDICATION NAME] (medication for bloating) 80 mg multiple dose bottle (100 tabs) opened and not dated; Geri kot (laxative medication) 8.6 mg multiple dose bottle (100 tabs) opened and not dated; Calcium [MEDICATION NAME] (medication for bone loss) 500 mg multiple dose bottle (150 tabs) opened and not dated; Fish oil 1000 mg multiple dose bottle (120 soft gels) opened and not dated; and Geri [MEDICATION NAME] (medication for cough) 1000 milliliters (ml) multiple dose bottle expired 12/2018. Observation of the 400 Hall medication cart on 3/5/19 with LPN #4 at 4:44 PM revealed 2 [MEDICATION NAME] protective foil packages opened and not dated; 10 [MEDICATION NAME] not dated and not stored in the protective foil package; 1 [MEDICATION NAME] (nasal spray for allergies [REDACTED].#22 gauge expired on 3/18; 2 tubes of [MEDICATION NAME] Ointment (topical ointment applied for pain relief) opened, unlabeled and not dated; Multi Dex powder tube (powder used to absorb wound drainage) opened, not dated and unlabeled; Derma Med Ointment tube (skin protectant ointment), opened, unlabeled and not dated; Sodium [MEDICATION NAME] (medication used as an antacid and also to reduce the acidity of the blood and urine) 650 mg multiple dose bottle (1000 tabs) opened and not dated; Mineral oil (oil laxative) multiple dose 16 ounce bottle expired 11/2018; [MEDICATION NAME] 160 mg/5 ml, a 16 ounce multiple dose bottle expired 2/2019; Iron Supplement [MEDICATION NAME] 220 mg/5 ml, a 16 ounce multiple dose bottle, unopened and expired 1/2019; and Geri-Mucil (liquid laxative medication) 10 ounce bottle expired 7/2018. Telephone interview with the Pharmacy Consultant on 3/7/19 at 8:25 AM revealed .The [MEDICATION NAME] R Insulin was definitely expired and should not have been on the medication cart, and the creams should not be with the oral medications . Further interview revealed .I do not check any over the counter multi dose bottles or intravenous equipment .The nurses restock the carts with over the counter medications from their central supply and the intravenous catheters should not even be on the cart .I check all the facility carts and give the Director of Nursing a detailed print out each month, and in (MONTH) I pulled all the expired medications off their carts .",2020-09-01
655,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,225,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to complete a thorough investigation following an allegation of abuse for one resident (#8) of eight residents reviewed for abuse. The findings included: Review of the facility Abuse Policy dated (MONTH) (YEAR), revealed .Investigation .the investigation shall include interviews of team members, visitors, residents/patients, volunteers .who may have knowledge of the alleged event . Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated 6/14/17 revealed .requires staff assistance for all ADL's (activity of daily living) .[DIAGNOSES REDACTED]. Medical record review revealed Resident #8 was unable to complete the Brief Interview for Mental Status due to a Dementia diagnosis. Review of a facility abuse investigation beginning 6/18/17, revealed Resident #8's daughter reported an allegation a staff member was mean as a snake to Resident #8 and squeezed his sore arm. The daughter alleged it occurred when the staff member positioned Resident #8 in bed on 6/17/17 on the third shift. Interview with the accused staff member on 9/12/17 at 10:40 AM, by phone, revealed she denied harming the resident and stated she no longer worked for the facility. Continued interview revealed she was not questioned about the alleged abuse and was not asked to provide a statement regarding the alleged abuse. Interview and review of the facility investigation with the Administrator and Social Worker on 9/12/17 at 10:45 AM, in the Administrator's office, confirmed the alleged perpetrator was not interviewed regarding the alleged abuse. Continued interview confirmed the facility failed to follow the facility abuse policy for investigating allegations of abuse.",2020-09-01
657,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,309,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to monitor and evaluate the effectiveness of interventions for identified behaviors in order to attain and maintain the highest practicable psychosocial well-being for 1 (Resident# 3) of 9 sampled residents. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/4/17, revealed Resident# 3 had a BIMS (Brief Interview for Mental Status) score of 14, indicative of intact cognitive status. Resident #3's Behavior Section of the MDS indicated [MEDICAL CONDITION] and other behavior not directed towards others. Medical record review of the plan of care developed on 3/24/08, revealed an established problem, Episodes of socially inappropriate behaviors AEB (as evidenced by) places washcloths down the front of his pants, urinates on floor and causes odor in his room, refuses care, may refuse showers at times due to his being embarrassed about his incontinence. Keeps urinal on bedside table. Interventions included: Explain the need for care trying to be provided; psych (psychiatric) eval (evaluation) and tx (treatment) as indicated; be calm in manner and approach. If resident is resistant try reproaching; encourage and then praise resident for using call light when assistance is needed; social services to visit prn (as needed); remind the resident of the need for good hygiene and odor control; Male tech if available and remove soiled linens from resident closet and bedside stand, dresser daily to eliminate odors. Medical record review of Nursing Notes, from (MONTH) and (MONTH) (YEAR) revealed on 7/18/17 at 9:07 PM Resident# 3 was noted with a history of poor hygiene habits such as pours urine at bedside. Hiding dirty laundry in closet. Medical record review of Nursing Notes dated 7/25/17 at 2:56 PM, revealed, When staff ask resident to change his clothes and to get shaved resident started yelling at staff. I'm not wet! Medical record review of Nursing Notes dated 7/31/17 at 6:32 AM, revealed, Refused x (times) 2 this morning to have brief changed which was wet, started yelling and cursing at nurse. Medical record review of Nursing Notes dated 8/8/17 at 11:15 PM, revealed, (Resident #3) was noted to like to pour urine on bedroom floor and hiding dirty laundry in closet, causing a strong smell in room and making his roommate very uncomfortable. Medical record review of the Nursing Note dated 8/16/17 at 1:13 AM, revealed, Has behavior issue such as pour urine on the floor often, hiding dirty laundry in places. Medical record review of Social Service documentation revealed no Social Services involvement regarding the identified behaviors. Interview with the Social Services Director (SSD) #1 on 9/12/17 at 8:30 AM, confirmed she had not been involved with Resident #3 and was not aware of Resident #3's inappropriate behaviors. Interview with the Director of Nursing (DON) on 9/12/17 at 10:00 AM, revealed monitoring of behaviors was documented by the nurses on the Medication Administration Record [REDACTED]. Further interview with the DON at 3:05 PM, after a review of Resident #3's MAR, confirmed the implementation of care plan approaches were not being monitored to evaluate effectiveness of interventions to further develop a systematic approach in care and services in order for Resident#3 to attain his highest practicable psychosocial well-being.",2020-09-01
658,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,514,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure an accurate medical record for one resident (#6) of nine residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Medical record review of the resident [DIAGNOSES REDACTED]. Medical record review of the resident current Medication Administration Record [REDACTED]. Interview and review of resident [DIAGNOSES REDACTED].#6 received the [DIAGNOSES REDACTED]. Further interview confirmed the resident was not hospitalized around the time of the 11/15/16, and was not being treated for [REDACTED]. Continued interview confirmed the resident's medical record was inaccurate.",2020-09-01
660,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,600,D,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.",2020-09-01
662,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2019-03-26,550,D,0,1,GERH11,"**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 promote resident rights to respect and dignity, and ensure privacy for 1 resident (#8) of 1 resident reviewed of 19 sampled residents. The findings include: Review of the facility policy Dignity and Respect, dated 7/91, revealed .Residents' individual preferences .clothing .are elicited and respected by the facility .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by . Review of the facility policy Activities of Daily Living, dated 3/17, revealed .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. Further review revealed dressing required extensive assistance of 2 staff members. Medical record review of Resident #8's care plan, dated 12/26/18, revealed .Assist me with bed mobility, transfers, toileting, grooming, dressing, and locomotion . Observation and family interview with Resident #8's family on 3/24/19 at 12:45 PM, in the resident's room, revealed the resident was .left in hospital clothes, and never has pants on . The resident was dressed in a hospital gown, without pants, at the time of the interview. Observation and family interview with Resident #8's family on 3/25/19 at 4:57 PM, in the resident's room, revealed the resident remains in bed dressed in a hospital gown, and no pants.I wish they would put clothes on him every day .it would make him feel better, and stay warmer . Observation of Resident #8 on 3/26/19 at 8:31 AM, from the 100 hallway, revealed resident lying disheveled, and uncovered with his legs and brief exposed. Interview with the Director of Nursing (DON) on 3/26/19 at 8:54 AM, in the 100 hallway, revealed it would depend on the resident's preferences and needs as to what clothing she would expect them to have on. Continued interview confirmed, .honestly, it is easier to provide care to some of them in a gown .if people are up and going to therapy, they need shirt and pants on . Interview with the DON on 3/26/19 at 9:10 AM, in the conference room, confirmed the facility failed to promote resident rights to respect and dignity, and to ensure privacy for Resident #8.",2020-09-01
664,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,657,D,0,1,Y2B811,"**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 (#71) of 18 sampled residents. The findings included: Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet Review of facility's Incident Case Report dated 4/10/18 with completion date of 5/1/18 revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bed pan. Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Review of Resident #71's current KARDEX revealed, no intervention for use of bedpan , further review revealed, .Fall interventions: Non-skid socks. Interview with CNA # 1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 used bedside commode (BSC) for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #71 following a fall.",2020-09-01
665,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,689,D,0,1,Y2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility investigation, medical record review, observation, and interview, the facility failed to implement a new intervention and monitor effectiveness of interventions after a fall for 1 resident (#71) of 4 residents reviewed for falls of 18 sampled residents. The findings included: Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet For 72 hours following the fall, staff will document .The resident's reaction/response to the new fall intervention placed . Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required staff assistance for transfers and toileting. Medical Record Review of progress notes dated 4/14/18 revealed, This nurse was approached by CNA and told that resident had fallen in the floor . Review of facility's Incident Case Report dated 4/10/18 (correct date 4/14/18) revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bedpan. Review of Resident #71's current KARDEX (not dated) revealed no intervention for the use of a bedpan. Further review revealed, .Fall interventions: Non-skid socks . Observation of Resident # 71 on 5/01/18 at 7:56 AM, in the resident's room, revealed the resident lying in bed with a bedside commode (BSC) and safety mat at the bedside. Observation of Resident #71 on 5/02/18 at 7:33 AM, in the resident's room, revealed a BSC and safety mat in place at the bedside. Interview with CNA #1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 uses a BSC for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 8:27 AM, in the DON's office, confirmed Resident #71's fall occurred on 4/14/18 and the Incident Case Report date of 4/10/18 was incorrect. Further interview confirmed after falls occur, the resident would be assessed, the DON would be called to assist with new interventions and staff would complete a report. Continued interview confirmed the Interdisciplinary Team would review the interventions the following day to ensure the new intervention was appropriate. Further interview confirmed the facility would monitor the effectiveness and resident's response of the new intervention for 3 days after a fall, and review/revise as needed. Continued interview confirmed the new interventions would be added to the Kardex and the care plan would be updated. Interview with Resident #71 on 5/02/18 at 9:38 AM, in the resident's room, confirmed Resident #71 used BSC or bathroom for toileting and stated, .I hate a bedpan . Interview with the DON on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to implement the new intervention and monitor effectiveness following Resident #71's fall.",2020-09-01
666,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,791,D,0,1,Y2B811,"**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 ensure dental services were provided for 1 resident (#17) of 18 sampled residents. The findings included: Review of the facility policy Dental Services - Professional, revised 3/17 revealed, .routine and emergency dental services are available to meet the resident's oral health .nursing services is responsible for notifying Social Services of a resident's need for dental services .Social Services personnel will be responsible for assisting the resident/family in making dental appointments . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed .Obvious or likely cavity or broken natural teeth . Observation of Resident #17 on 4/30/18 at 10:34 AM, in the resident's room revealed the resident with tooth decay. Interview with the Director of Social Services on 5/2/18 at 8:20 AM, in the Social Services Office, confirmed Resident #17 had tooth decay and was scheduled to be seen by dental services on 4/20/18. Further interview confirmed Resident #17 was not seen by dental services on 4/20/18 despite being scheduled. Continued interview confirmed the facility failed to provide dental services for Resident #17 since admission to the facility on [DATE].",2020-09-01
667,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,880,D,0,1,Y2B811,"**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 post an isolation precaution sign on the door of 1 Resident (#328) of 3 residents on isolation precautions of 18 residents sampled of 73 total residents. The findings included: Review of the facility policy Reverse Isolation revised 11/17 revealed, .Place 'Please see nurse before entering room' sign on the outer door . Medical record review revealed Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order dated 4/25/18 revealed, .reverse isolation (isolation procedures designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors) for [DIAGNOSES REDACTED] (an abnormally low count of a type of white blood cell) . Medical record review of the care plan dated 4/25/18 revealed, .I am in reverse isolation because my immune system is low and I am susceptible to bacteria/viruses .Post signs at my door informing visitors to check in with licensed staff prior to entering room . Observation during initial tour of Resident #328's room, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed no isolation precaution sign on the door. Interview with Certified Nurses Aid (CNA) #2, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed Resident #328 was on reverse isolation precautions and a mask needed to be worn when entering the resident's room for his protection. Interview with the Registered Nurse Consultant, on 4/30/18 at 10:06 AM, in the Station 3 hallway, confirmed Resident #328 was on reverse isolation precautions and the facilty failed to post a sign on the resident's door to notify staff and visitors of the reverse isolation.",2020-09-01
668,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,641,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and interview, the facility failed to accurately assess residents for hospice and medications for 2 of 31 (Resident #88 and 99) sampled residents reviewed. The findings included: 1. Medical Record review revealed Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Physicians orders dated 3/21/17 documented, .Admit to (Named Hospice) .for Abnormal Weight Loss . The care plan dated 3/20/17 and updated 10/2/17 documented, .Problem/Need .Resident has chosen to receive Hospice Care with (Named Hospice) . The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #88 was receiving Hospice Care. The quarterly MDS dated [DATE] did not document Resident #88 was receiving hospice care. Interview with MDS Coordinator #1 on 1/24/18 at 3:50 PM, in MDS office, MDS Coordinator #1 was asked if hospice services was on the MDS dated [DATE]. She stated,No it is not there. She was asked if this would be an error. She stated, Yes. 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5-day MDS assessment dated [DATE] documented opioid was given 6 days of the 7 day look back period. The October, (YEAR) Medication Administration Record [REDACTED]. The admission MDS assessment dated [DATE] documented Resident #99 received opioids 3 days of the 7 day look back period. The November, (YEAR) MAR indicated [REDACTED]. Interview with the Administrator and the Director of Nursing (DON) on 01/25/18 at 7:48 PM, in the conference room, they confirmed this MDS information was inaccurate.",2020-09-01
669,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,692,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician diet orders for 1 of 5 (Resident #121) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].DIET .NAS (no added salt) pureed diet .fortified foods at all meals .fortified milkshakes w/ (with) lunch & dinner .double portions at all meals . The care plan dated 1/9/17 reviewed 1/8/18 documented, .Requires NAS/Pureed/Double Entree/Fortified Food tid (three times a day) Milk shake with lunch and dinner . 2. Observations on the second floor dining room on 1/24/18 at 11:50 PM, revealed Resident #121's meal tray with a meal ticket that documented, .Diet: Pureed, NAS, Fortified Foods . A milk shake was not observed on Resident #121's meal tray. Observations on the second floor dining room on 1/24/18 at 6:10 PM, revealed Resident #121's meal tray consisted of pureed broccoli, pureed corn, pureed chicken, pureed bread, and a carton of milk. A milk shake was not observed on Resident #121's tray. Observations on the second floor dining room on 1/25/18 at 8:30 AM, revealed Resident #121 being assisted with her breakfast. Her breakfast consisted of pureed eggs, sausage, toast, milk. 3. Interview with Certified Nursing Assistant (CNA)#1 on 1/25/18 at 8:32 AM, in the dining room, CNA #1 was asked if Resident #121's breakfast tray contained double portions. CNA #1 stated, No. Interview with the Dietary Tech and Kitchen Manager on 1/25/18 at 9:54 AM, in the main dining room, the Dietary Tech was asked what her job responsibilities were. The Dietary Tech stated, .I take care of the clinical part for the facility and charting . The Dietary Tech and Kitchen Manager were asked what Resident #121 was supposed to receive on her meal tray. The Dietary Tech stated, .Puree, NAS, Fortified Foods, milk shakes on lunch and dinner tray, double portions on lunch and dinner tray, and med pass tid . The Kitchen Manager stated, .she gets fortified oatmeal on her breakfast tray .double portion with fortified food and milk shake on her lunch tray, and double portions with fortified foods and milk shake on her dinner tray . The Kitchen Manager was shown Resident #121's meal ticket and asked (looking at the meal ticket), would the CNA know that the resident was supposed to receive double portions and milk shakes. The Kitchen Manager stated, .absolutely not .",2020-09-01
670,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,842,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to have a complete and accurate medical record for Activities of Daily Living (ADLs) and medications for 2 of 31 (Resident #33 and #99) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and quarterly MDS assessment dated [DATE] documented Resident #33 was cognitively intact, required extensive assistance with activities of daily living, had functional limitations in range of motion with impairment in both lower extremities. The care plan dated 8/23/16 documented Resident #33 had a self-care deficit with interventions to provide a shower or bath according to the schedule. The ADL Flow Record did not document Resident #33 had a shower or bath on 10/1/17, 10/2/17, 10/3/17, 10/4/17, 10/5/17, 10/6/17, 10/7/17, 10/8/17, 10/23/17, 10/24/17, 10/25/17, 10/26/17, 10/27/17, and 10/28/17. The ADL Flow Record did not document Resident #33 had a shower or bath on 11/8/17, 11/9/17, 11/10/17, 11/11/17, and 11/12/17. The ADL Flow Record did not document Resident #33 had a shower or bath on 12/23/17, 12/24/17, 12/25/17, 11/26/17, and 11/27/17. The ADL Flow Record did not document Resident #33 had a shower or 1/1/18, 1/2/18, 1/3/18, 1/4/18, 1/16/18, 1/17/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, and 1/22/18. Interview with Licensed Practical Nurse (LPN) #1 and 2nd floor Unit Manager on 1/25/18 at 8:20 AM, at the 2nd floor nurses station, the Unit Manager stated, .if it's not documented, it's (shower) not been done . LPN #1 continued to state, she gets her showers even though we don't have the documentation to back that statement up .otherwise she would be calling ya'll (state) to file a complaint . Interview with Resident #33 on 1/23/18 at 8:45 AM, in Resident #33's room, Resident #33 stated, .I got a shower last week and thank God for that .It's the first shower I've gotten in 2 months .they are not very regular with the showers . 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CONTROLLED SUBSTANCES form documented [MEDICATION NAME] ([MEDICATION NAME]) was signed out for Resident #99 on 10/28/17 at 10:00 AM, 10/29/17 at 11:00 AM, 10/30/17 at 11:00 AM and at 5:00 PM, and 10/31/17 at 10:00 AM. The October, (YEAR) Medication Administration Record [REDACTED]. The CONTROLLED SUBSTANCES form documented [MEDICATION NAME] ([MEDICATION NAME]) was signed out for Resident #99 on 11/4/17 at 2:00 PM, 11/5/17 at 11:00 AM, 11/10/17 at 8:00 AM, 11/12/17 at 6:00 AM, 11/15/17 at 10:00 AM, 11/16/17 at 10:00 AM, 11/17/17 at 10:00 AM, 11/18/17 at 10:00 AM, 11/20/17 at 10:00 AM, and at 5:00 PM, 11/21/17 at 2:00 AM, and at 11:00 AM, 11/22/17 at 10:00 AM, 11/23/17 at 10:00 AM, 11/24/17 at 10:00 AM, 11/25/17 at 10:00 AM, 11/27/17 at 8:30 AM, 11/28/17 at 10:00 AM, and 11/30/17 at 10:00 AM. The November, (YEAR) MAR indicated [REDACTED]. Interview with the Administrator and the Director of Nursing on 1/25/18 at 7:48 PM, in the conference room, they confirmed this medical record was inaccurate.",2020-09-01
671,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,580,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the physician and resident representative were notified of the use of oxygen, antibiotic therapy, breathing treatments and a recent [DIAGNOSES REDACTED].#5 and #6) sampled residents. The findings include: 1. The facility's Change in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly .Except in medical emergencies, notifications of a change occurring in the resident's medical/mental condition or status will be made . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT (RT #2) on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked if the physician or family was notified of the need for oxygen. RT #2 stated, I didn't. I guess not. Medical record review revealed there was no documentation the physician or the family had been notified of the changes in Resident #5's condition or the need for the use of oxygen. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 2/5/19 documented, .CXR (chest x-ray) due to congestion, cough, rales . Review of the Telephone Orders dated 2/6/19 documented, .[MEDICATION NAME] (an antibiotic used to treat a bacterial infection) 250 mg PO (by mouth) tab (tablet) BID (twice daily) for pneumonia For 7 days .[MEDICATION NAME] sulfate (a [MEDICATION NAME][MEDICATION NAME]) 0.083% (percent) 2-5-3 mg (milligram) INH (inhalation) Q (every) 8 hrs (hours) for 7 days . Review of a Progress Note dated 2/6/19 documented, .CHEST X-RAY RESULTS RECEIVED; LEFT LOWER LOBE PNEUMONIA FOUND . Medical record review revealed there was no documentation Resident #6's family/representative had been notified of the change in condition, the results of the chest x-ray,the new [DIAGNOSES REDACTED].",2020-09-01
673,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,684,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol, medical record review, and interview, the facility failed to ensure physician orders [REDACTED].#5) sampled residents. The findings include: 1. The facility's Clinical Pathways protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do . RT #2 was asked if Resident #5 had chest pain or shortness of breath. RT #2 stated, No. During a telephone interview with LPN #2 on 2/28/19 at 2:18 PM, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if there was a physician order [REDACTED]. During an interview with the Director of Nursing (DON) ) on 2/28/19 at 2:02 PM in the conference room, the DON was asked if there was an order for [REDACTED]. TUMS is what we have as house stock . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was included in the facility's standing orders protocol. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs.",2020-09-01
674,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,697,D,1,0,TO3W11,"**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].#12) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #12 was admitted to the facility with Hospice services on 2/12/19 at 2:00 PM with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED].[MEDICATION NAME] ER (extended release) 60 mg (milligram) tablet take one tablet po (by mouth) q (every) 12 hrs (hours) . Review of the ADMINISTRATION RECORD dated 2/12/19 revealed the [MEDICATION NAME] ER 60 mg po was not administered as ordered on [DATE] or 2/13/19. Review of the Comprehensive Care Plan documented, .has potential for pain related to [MEDICAL CONDITION] .Administer medication for pain as ordered and document effectiveness . 2. During an interview with Registered Nurse (RN) #1 on 3/5/19 at 10:45 AM in the conference room, RN #1 was asked what time Resident #12 received the [MEDICATION NAME] ER as ordered. RN #1 stated, On the 13th at 9:00 AM a prn (as needed) dose .Didn't get it ([MEDICATION NAME] ER 60 mg) on the 12th. During an interview with Licensed Practical Nurse (LPN) #3 on 3/10/19 at 3:55 PM at the 200 Hall nurses' desk, LPN #3 was asked if Resident #12 was given his pain medication as ordered when he was admitted on [DATE]. LPN #3 stated, If Hospice is bringing them we would use from Hospice. He did not come with his meds. We should have gotten a hard script for the [MEDICATION NAME] and sent to pharmacy. We would get the next day in the evening. During review of Resident #12's Administration Record with LPN #3, she was asked if the first dose of the scheduled [MEDICATION NAME] ER 60 mg was given on 2/13/19 at 6:00 PM. LPN #3 stated, Correct. During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the DON office, the DON was asked when Resident #12 received the [MEDICATION NAME] ER 60 mg tablet that was ordered every 12 hours. The DON stated, On new admits (admissions) we don't get their meds (medications) till the evening run the next day. Evening run is at 5:00 PM or later. Nurse says between 9:00 PM and 9:30 PM the next evening. We didn't have it since Hospice didn't bring it . The DON confirmed Resident #12 did not receive the scheduled [MEDICATION NAME] ER 60 mg every 12 hours as ordered on admission on 2/12/19 and 2/13/19.",2020-09-01
677,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,842,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide and maintain accurate, complete medical records for 2 of 12 (Resident # 5 and 7) sampled residents. The findings include: 1. The facility's Charting and Documentation policy documented, .All observations, medications administered, services provided, etc., must be documented in the resident's clinical records .All incidents, accidents, or changes in the resident's condition must be recorded . The facility's Change in a Resident's Condition or Status policy documented, .The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility's Clinical Pathways (standing orders) protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed there was no documentation of an assessment of Resident #5 on 2/16/19 or 2/17/19 and no documentation of the administration of oxygen or TUMS to the resident. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do .I didn't document it. I should have put it in a general note . RT #2 was asked if the resident had chest pain or shortness of breath. RT #2 stated, No. During an interview with Licensed Practical Nurse (LPN) #2 on 2/28/19 at 2:18 PM at the 200 Hall nurses' station, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if she documented the administration of TUMS and she stated, I wrote it on a piece of paper. I didn't document in the computer. I didn't document in his record. LPN #2 was asked if there was a physician's orders [REDACTED]. LPN #2 stated, I thought it was on standing orders. I know [MEDICATION NAME] is on it . During an interview with the Director of Nursing (DON) on 3/5/19 at 3:10 PM in the conference room, the DON was asked how staff would know the oxygen and TUMS were administered if there was no documentation. The DON stated, We don't. Should be documented. The DON was asked what the expectation was for documentation of assessments and changes in a resident's condition. The DON stated, Chart skilled assessments daily and chart every shift at times . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was on the facility's standing orders. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs. 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a [MEDICAL CONDITION] Note dated 2/26/19 documented, .Resident complain of SOB (shortness of breath) and requested to be on a little o2 (oxygen). RT checked his o2 sats (oxygen saturation) they were 92%, HR (heart rate) 88, rr (respiratory rate) 20. RT placed resident on 2L (liter) bnc (by nasal cannula). SPo2 (peripheral capillary oxygen saturation) came up to 98%, HR 38, rr 20. No distress noted . During a telephone interview with RT #3 on 3/5/19 at 4:22 PM, RT #3 stated, I charted that wrong. That's an error. Heart Rate was 83 . During an interview with the DON on 3/5/19 at 11:10 AM in the Administrator's office, the DON was asked if the heart rate of 38 was correct as documented. The DON looked at the [MEDICAL CONDITION] note and stated, That can't be correct .",2020-09-01
678,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,690,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to ensure laboratory services were provided as ordered by the physician for 1 of 3 (Resident #5) residents reviewed for urinary tract infection. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].UA (urinalysis) & (and) Culture . Interview with the Director of Nursing (DON) on 7/5/18 at 11:37 AM, in the administrator's office, the DON was asked if the urinalysis was collected for Resident #5. The DON stated, No .we were unable to find the labs (laboratory test results) ordered by the physician on 1/31/18 . The DON was asked if it was acceptable to not follow doctor orders for labs. The DON stated, No.",2020-09-01
679,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,695,D,1,0,MQID11,"**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 proper [MEDICAL CONDITION] care for 1 of 3 (Resident #3) residents observed with a [MEDICAL CONDITION]. The findings included: 1. The facility's [MEDICAL CONDITION] Care policy documented, .[MEDICAL CONDITION] should be changed as ordered and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The physician's orders [REDACTED].TRACH ([MEDICAL CONDITION]) CARE Q SHIFT (every shift) . The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was assessed with [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of the MARs dated (MONTH) and (MONTH) (YEAR) revealed no documentation of [MEDICAL CONDITION] care provided on either shift. Observations in Resident #3's room on 7/3/18 at 10:00 AM, revealed a large amount of thick, creamy secretions flowed from the end of the resident's [MEDICAL CONDITION] and pooled on her upper chest. Observations in Resident #3's room on 7/3/18 at 1:19 PM, revealed a small amount of thick, creamy secretions flowed from the end of the residents [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #1 on 7/3/18 at 10:00 AM, in Resident #3's room, LPN #1 was asked how often [MEDICAL CONDITION] care is performed on the resident. LPN #1 stated, .It's not due .the night shift nurse told me she did it . Interview with the Director of Nursing (DON) on 7/3/18 at 1:38 PM, in the administrator's office, the DON was asked how often [MEDICAL CONDITION] care should be performed. The DON stated, Every shift .and as needed. The DON was asked if she could tell me where the [MEDICAL CONDITION] care was documented. The DON stated, .On the MAR's . The DON was asked if it was acceptable to not perform or document [MEDICAL CONDITION] care. The DON stated, .No .it should be documented .",2020-09-01
680,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-07-30,686,D,1,0,MKNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to follow physician orders [REDACTED].#2 and #3) sampled residents reviewed with pressure ulcers. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Clean sacral wound c (with) NS (normal saline). Pat dry. Apply Santyl oint. (ointment) to slough. Apply collagen & (and) calcium alginate to wound bed. Cover c protective dressing. (symbol for change) QD (everyday) & PRN (as needed) Observations in Resident #2's room on 7/30/19 at 11:22 AM, revealed Treatment Nurse #1 did not apply the Collagen dressing to the wound bed during wound care. Interview with Treatment Nurse #1 on 7/30/19 at 4:40 PM, at the First Floor Nursing desk, the Treatment Nurse #1 was asked were the physician orders [REDACTED]. Treatment Nurse #1 stated, .I didn't put the Collagen, I forgot . Medical record review revealed Resident #3 was admitted to facility 3/20/19 with [DIAGNOSES REDACTED]. The physicians's order dated 7/13/19 documented, .Cleanse area to sacrum, R (right) hip c NS, pat dry, apply santyl + (and) cover drsg (dressing) (symbol for change) QD + PRN . Observations in Resident #3's room on 7/30/19 at 1:36 PM, revealed Treatment Nurse #2 applied Santyl ointment to a Calcium Alginate dressing and applied to the wound bed, and then applied the a cover dressing during wound care. Interview with Director of Nursing (DON) on 7/30/19 at 4:15 PM, at the First Floor Nursing desk, the DON was shown the physician order [REDACTED].#2 have applied Calcium Alginate to this wound. The DON stated, No .",2020-09-01
681,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,580,D,1,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to immediately notify the physician of [DIAGNOSES REDACTED] (low blood glucose level results) for 1 of 3 (Resident #36) sampled residents reviewed for significant change in condition. The findings include: Medical record review revealed Resident #36 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A progress notes dated 9/8/19 at 10:31 PM, documented, .at the beginning of the tour pt's (patient's) blood sugar was 115, No insulin was given. one hour later pt's blood sugar had dropped 48. pt (Patient) was given PEPSI cola, 1 amp ([MEDICATION NAME]) of [MEDICATION NAME] ([MEDICATION NAME]), 1 carton of milk with 2 packs of sugar, 1 small can of sprite. 20 minutes later pt's blood sugar was 101. pt was not given any insulin this tour. pt will continue to be monitored. The facility was unable to provide documentation that the physician was immediately notified on 9/8/19 of the low blood glucose level of 48. A progress note dated 9/18/19 at 2:52 AM, documented, [MEDICATION NAME] 1 MG (milligram) HYPOKIT Inject 1 mg subcutaneously as needed for BLOOD SUGAR BELOW 50 AND UNCONSCIOUS OR UNABLE TO SWALLOW .BLOOD SUGAR 40, resident unable to swallowing (swallow) just letting juice run down face. The facility was unable to provide documentation that the physician was immediately notified on 9/18/19 of the low blood glucose level of 40. Interview with the Director of Nursing (DON) on 10/21/19 at 1:30 PM, in the Conference room, the DON confirmed the facility was unable to provide documentation the physician was immediately notified of Resident #36's change in condition of [DIAGNOSES REDACTED] and that the physician should have been notified of these [DIAGNOSES REDACTED] episodes.",2020-09-01
682,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,761,D,0,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to ensure medications were stored properly when expired medications were found in 1 of 11(First Floor Medication Room) medication storage areas. The findings include: The undated Storage of Medications policy documented, .The nursing staff shall be responsible for maintaining medication storage .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals . Observations in the First Floor Medication Room on 10/22/19 at 2:35 PM, revealed the following medications were stored past the expiration date: a. Three boxes of Influenza Vaccine vials with an expiration date of 7/30/19. b. One 1000 milliliter bag of 5% (percent) [MEDICATION NAME] with 1/2 normal saline with an expiration date of (MONTH) 2019. c. [MEDICATION NAME] Sodium premixed in 100 milliliters normal saline with an expiration date of 8/26/19. Interview with the Director of Nursing (DON) on 10/22/19 at 2:40 PM, in the First Floor Medication Room, the DON was asked should expired medications be in this storage area. The DON stated, No, they should not.",2020-09-01
683,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,880,D,1,1,IWI711,"**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 maintained when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly disinfect a glucometer (glucose testing machine) after use and when 1 of 1 (Respiratory Therapist (RT) #1) staff failed to perform proper hand hygiene during [MEDICAL CONDITION] care. The findings include: 1. The undated policy Cleaning and Disinfecting Your Even-Care G2 Meter documented, .Purpose: Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious diseases .Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface . 4. To disinfect your meter clean the meter with one of the validated disinfecting wipes listed below .Micro-Kill Bleach Germicidal Bleach Wipes . Observations in Resident #36's room on 10/16/19 at 4:23 PM, revealed RN #1 preformed a blood glucose check and then cleaned the glucometer with an alcohol pad. RN #1 did not use the Micro-Kill Bleach Germicidal Bleach Wipe to disinfect the glucometer. Interview with the Director of Nursing (DON) on 10/21/19 at 1:25 PM, in the Conference Room, the DON confirmed the glucometers should be disinfected with Micro-Kill Bleach Germicidal Bleach Wipes. 2. The [MEDICAL CONDITION] Care policy with a revision date of (MONTH) 2014 documented, Remove old dressings .Wash hands .Put on sterile gloves .remove the inner cannula .Remove and discard gloves .Wash hands and put on fresh gloves .Replace the cannula . Observations of [MEDICAL CONDITION] care in Resident #10's room on 10/22/19 at 8:07 AM, revealed RT #1 removed the [MEDICAL CONDITION] dressing and inner cannula with sterile gloves and then performed [MEDICAL CONDITION] care and replaced the sterile inner cannula without performing hand hygiene or applying new sterile gloves. Interview with the Director of Nursing (DON) on 10/22/19 at 10:09 AM, in the Administrator Office, the DON was asked should the Respiratory Therapist change gloves and perform hand hygiene after removing a dirty inner cannula and cleaning the [MEDICAL CONDITION] site. The DON stated, Yes.",2020-09-01
687,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,550,D,0,1,G6WX11,"Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when an indwelling urinary catheter bag was not in a dignity bag for 1 of 6 (Resident #111) sampled residents reviewed with an indwelling urinary catheter. The findings include: The facility's Quality of Life - Dignity policy with a revision date of October, 2009 documented, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Observations in Resident #111's room on 12/3/18 at 11:12 AM, 3:54 PM, and on 12/4/18 at 3:13 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter and the catheter drainage bag was not in a dignity bag. The urine in the bag could be seen from the hallway when walking by the room. Observations in the 2nd Floor Dining room on 12/3/18 at 12:10 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter and the catheter drainage bag was not in a dignity bag. Interview with the Director of Nursing (DON) on 12/5/18 at 11:45 AM in the Conference Room, the DON was asked if an indwelling urinary catheter drainage bag should be in a dignity bag. The DON stated, Yes.",2020-09-01
688,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,641,D,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess residents for nutrition and hospice for 3 of 32 (Resident #36, 96, and 136) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the following weights: 3/9/18 - 195 pounds (lbs) 4/11/18 - 196.2 lbs 5/10/18 - 196.8 lbs 6/15/18 - 197 lbs 7/12/18 - 195.2 lbs 8/10/18 - 217.4 lbs 9/5/18 - 223 lbs The weight gain of 28 lbs in 6 months resulted in a 14.36 percent (%) significant weight gain. Medical record review did not reveal a physician prescribed weight gain program. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed yes to significant weight gain and the resident was on a physician-prescribed weight gain regimen. Interview with Dietary Technician #1 on 12/6/18 at 11:09 AM in the Administrative Offices, Dietary Technician #1 was asked about the assessment the resident had a significant weight gain and was on a weight gain program. Dietary Technician #1 confirmed this MDS was inaccurate and stated, Oh, I checked the wrong thing. 2. Medical record review revealed Resident #96 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The quarterly MDS assessment dated [DATE] was not coded for hospice. Interview with MDS Coordinator #1 on 11/6/18 at 12:45 pm in the MDS office, MDS coordinator #1 was asked if the MDS dated [DATE] was coded correctly for hospice. MDS coordinator #1 stated, No ma'am. 3. Medical record review revealed Resident #136 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the following weights: 4/11/18 - 168.6 lbs 5/10/18 -168 lbs 6/15/18 - 165 lbs 7/12/18 - 160 lbs 8/10/18 - 139.6 lbs 8/29/18 - 138 lbs 9/5/18 - 134 lbs 9/12/18 - 134.4 lbs 9/19/18 - 138.5 lbs 9/25/18 - 138.4 lbs 10/10/18 - 137.6 lbs 11/9/18 - 135 lbs 11/28/18 - 131 lbs The weight loss of 20.4 lbs from 7/12/18 to 8/10/18 resulted in a significant weight loss of 12.75 % in one month. Medical record review did not document a physician prescribed weight loss program. The quarterly MDS assessment dated [DATE] revealed a significant weight loss in the last month or 6 months and the resident was on a physician prescribed weight loss program. The weight loss of 31 lbs from 4/11/18 to 10/10/18 resulted in a significant weight loss of 18.39 % in 6 months. The significant change MDS assessment dated [DATE] revealed no significant weight loss in the last month or 6 months. Interview with Dietary Technician #1 on 12/5/18 at 4:19 PM in the Conference Room, Dietary Technician #1 was asked about the MDS assessment dated [DATE] which revealed significant weight loss and a physician prescribed weight loss program. Dietary Technician #1 confirmed this was inaccurate and stated, I hit the wrong button. Dietary Technician #1 was asked about the 11/7/18 MDS with no significant weight loss checked. She confirmed this was inaccurate, and stated I don't think I went back 6 months.",2020-09-01
689,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,690,D,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 2 of 6 (Resident #3 and 42) sampled residents reviewed for indwelling urinary catheters. The findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOLEY CATH (catheter) CARE Q (every) SHIFT/PRN (as needed) . Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOELY (Foley) CATH CARE QSHIFT/PRN . Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/5/18 at 4:45 PM in the Conference Room, the DON was asked if it was acceptable to not follow physician's orders [REDACTED]. The DON stated, No its not.",2020-09-01
690,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,761,D,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were securely and properly stored when 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses left a medication cart unlocked and insulin was not dated when opened in 1 of 6 (100 Hall Cart 2 medication cart) medication storage areas. The findings include: 1. The facility's Storage of Medications policy with a revision date of April, (YEAR) documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use . Observations in the 200 hall in front of the Nurses' Station beginning on 12/4/18 at 11:32 AM revealed LPN #1 prepared supplies to perform an accucheck, walked down the hall to Resident #125's room to perform the accucheck, and left the unlocked medication cart unattended and out of sight. At 11:40 AM LPN #1 returned to the cart and prepared insulin for Resident #125. LPN #1 walked down the hall to administer the insulin to the resident and left the unlocked medication cart unattended and out of sight. Interview with Registered Nurse (RN) #1 on 12/4/18 at 11:58 AM, RN #1 was asked if she had locked this medication cart. She confirmed the medication had been unlocked and stated, Yes Ma'am, I did. Interview with the Director of Nursing (DON) on 12/5/18 at 11:45 AM in the Conference room, the DON was asked if the medication cart should be left unlocked. The DON stated, Oh my God .No. 2. The facility's Insulin Administration policy revised (MONTH) 2010 documented, If opening a new vial, record expiration date and the date you open the vial .pen . Observations at the 100 Hall Cart 2 medication cart on 12/6/18 at 12:15 PM, revealed 1 vial of Regular [MEDICATION NAME]with no open date, 1 [MEDICATION NAME]pen with no open date, and 2 [MEDICATION NAME] pens with no open date. The multi dose insulins had been opened and in use. Interview with RN #2 on 12/6/18 at 12:15 PM, at the 100 Hall Cart 2 medication cart, RN #2 confirmed the insulin should have been dated when opened. Interview with the DON on 12/6/18 at 2:15 PM, in the Conference room, the DON was asked should insulin be dated when opened. The DON stated, Yes it should.",2020-09-01
692,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,656,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to address the resident's issues with oral care for 1 resident (#2) of 5 residents reviewed. Findings include: Review of facility policy, Oral Hygiene, undated, revealed .Designated partners will provide care of mouth and teeth to all patients every morning and evening as needed to prevent mouth infections; prevent dental decay; prevent gum disease; and promote personal hygiene .Gently clean patient's teeth .Inspect oral cavity . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 Brief Interview for Mental Status (BIMS) scored as 3 and severely impaired cognitively. Continued review of the MDS revealed Resident #3 was dependent on 2 people for transfers; required extensive assistance of 1 person for dressing, eating; extensive assistance of 2 people for grooming; was dependent on 1 person for bathing; had functional limitations in both lower extremities; was frequently incontinent of bladder and always incontinent of bowel. Medical record review of the Activities of Daily Living (ADL) record revealed documentation Resident #3 received personal hygiene twice daily. Continued review revealed out of 40 opportunities for oral care, it was documented he received care on 24 occasions. Medical record review of a Speech Therapy evaluation dated 11/24/17 revealed Resident #3 had his natural teeth. Continued review revealed he had decreased bolus control (problems swallowing solid food). Further assessment revealed medication from earlier administration was noted in the oral cavity. Medical record review of weights revealed Resident #3 weighed 126 pounds on admission to the facility. Continued review revealed weight on 11/22/17 was 125 pounds; on 11/23/17 weight was 125 pounds. Further review revealed on 11/29/17 weight was 122 pounds and on 12/6/17 weight was 120 pounds. Continued review revealed Resident #3 refused to be weighed on 12/13/17. Medical record review of a Nutrition consult dated 12/4/17 revealed Resident #3 had poor intake, consuming Medical record review of the Care Plan dated 11/22/17 revealed Resident #3 was at risk for alteration in nutritional status/weight loss related to swallowing difficulty; age; polypharmacy; and [MEDICAL CONDITION]. Continued review revealed interventions included to adjust diet consistency as needed; mechanical soft with ground meat with gravy and high calorie diet; nutritional supplements of Ensure Clear 3 times daily with meals and House Supplement twice daily; encourage fluids between meals; adaptive equipment as needed; assist with meals; dietician assessment in progress. Medical record review revealed no documentation of any issues with oral care until 12/11/17 when nursing documented .Attempted to provide oral care on resident. Was able to get swab in mouth after coaching. As soon as swab placed in mouth pt. bit down and would not allow nurse to clean mouth. With help of therapist finally got resident to release bite on swab so it could be removed. Oral care not completed because resident refused . Medical record review of the care plan revealed no documentation of issues with oral care such as pocketing food and biting down on swabs. Medical record review of the Provider Progress Note dated 12/12/17 revealed .One of the daughters is very upset because she feels oral care has not been adequate. However, nursing staff have been very diligent to provide oral care and patient will frequently not except oral care by clenching teeth and biting sponges. Speech Therapy has really worked with patient on this and will be teaching family how to perform oral care as well so patient may respond to a more familiar person. Registered dietitian reports he is still only receiving around 20 bites of food an hour. Patient frequently pockets food in this puts him at great risk for aspiration pneumonia. Labs showed he was maintaining renal function okay, no dehydration notes. Failure to thrive - patient's prognosis is poor and not likely to make meaningful recovery . Medical record review of a Provider Progress Note dated 12/19/17 revealed .Diligent oral care has been attempted but patient will frequently clench and bite sponges which make cleaning difficult for nursing staff. Patient also pockets food in this puts him at great risk for aspiration pneumonia. Unfortunately he is experiencing failure to thrive. Patient's daughter is not accepting of this diagnosis . Interview with the Director of Nursing (DON) on 2/14/18 at 11:55 AM in the conference room revealed staff had tried to perform oral care for Resident #2 but he clamped down on the swab or anything placed in his mouth. Continued interview with the DON confirmed the care plan did not include the fact Resident #2 pocketed his food and also he clamped down on the swab. Further interview confirmed there were no interventions for addressing these issues.",2020-09-01
693,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,689,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure residents had adequate supervision to prevent falls for 1 resident (#1) of 3 residents reviewed for falls. The findings included: 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 Resident #1 was scored 99 on BIMS ( Brief Interview for Mental score ) of 99 indicating severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance of 1 person for transfers, ambulation, dressing, eating, grooming, and bathing; was occasionally incontinent of bowel and bladder; and had functional limitation of 1 upper extremity. Medical record review of the Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted with a [MEDICAL CONDITION], left humerus and ulna fractures. Continued review revealed the injury was non-operative and would be conservatively managed. Further review revealed Resident #1 had a small right convexity subdural hematoma (collection of blood in the brain on the top right side of the head) and a large left superior convexity subdural hematoma. Medical record review of the care plan dated [DATE] revealed a problem of being at risk for complications related to behavior - refuses care, combative, agitated, disorganized thoughts. Continued review of the care plan revealed Resident #1 had a problem of being at risk for orthopedic complications related to fall with fracture, refusal to wear C-collar (cervical collar), non-compliant with weight-bearing status from the humerus and ulna fracture. Further review revealed interventions included assess for signs/symptoms of infection at surgical site; notify physician of signs/symptoms of complications; Occupational Therapy screen; observe for signs/symptoms of [MEDICAL CONDITION]. Medical record review of a Provider Progress Note dated [DATE] revealed .Patient has been very lethargic and vomited x2 today. Patient's medications have been titrated due to agitation from dementia. Patient had recent titration up on [MEDICATION NAME] to 2 times daily. She also had [MEDICATION NAME] 2 times daily. [MEDICATION NAME] as needed. Nausea with vomiting - new problem. Patient did not have any recent falls. Will go ahead and initiate neuro checks as she does have history of recent new subdural hematoma. Medical record review of a Post Fall Initial Note dated [DATE] revealed on [DATE] at 5:15 PM Resident #1 was found lying on the floor in fetal position in the activities room. Continued review revealed she had been walking in the room unassisted. Further review of the note revealed the following questions: 1. Did the patient have pain after the fall? Yes 2. Description of injury: Right fracture femur 3. First aid treatment administered: X-ray sent to ER (emergency room ) for evaluation 4. Right hip range of motion: Unable to perform Review of facility investigation revealed a written statement from Certified Nurse Aide (CNA) #5 dated [DATE] at 5:30 PM, which stated .I was doing rounds and observed patient on the floor. I called for a nurse. The nurse checked her and I ran vitals, and safely assisted resident to wheelchair . Review of facility investigation revealed a statement from Registered Nurse (RN) #1 dated [DATE] which stated .Patient did not appear uncomfortable on [DATE] or [DATE]. When the tech went to get patient OOB (out of bed) patient called out in discomfort. Patient was left in bed and nurse practitioner notified on morning of [DATE] . Review of facility investigation revealed a statement from CNA #1, dated [DATE] which stated .While providing daily care during AM shift (6A - 2P) on 24th and 25th I noted no increased pain in (named resident) when getting her cleaned and up to the chair. On morning of ,[DATE] I went to get her up and saw her frown like she may be in pain so I left her in bed and went to tell nurses who came to check on patient when I told them . Review of facility investigation revealed a statement from Licensed Practical Nurse (LPN) #2 dated [DATE] which stated .At time of fall patient was assessed, no c/o (complaint of ) pain, and no apparent injuries notes. Scheduled Tylenol given as ordered as patient had been getting this prior to fall. Review of facility investigation revealed a statement from RN #3 dated ,[DATE] 18 who stated .I took care of the patient approximately 24 hours post fall on a Saturday evening shift. The patient was not in increased pain and did not otherwise show any signs of change of function during my shift. I decided to put the patient in bed and perform neurological checks per post-fall protocol. The patient was comfortable in bed and all vital signs were stable during the shift . Review of facility investigation of an undated statement from LPN #3, revealed .I worked Saturday 23rd. (named resident #1) was resting in bed most of that double shift. I did not notice any acute distress or discomfort that weekend . Medical record review of a Change in Condition report dated [DATE] revealed .Pt crying with complaints of pain upon getting up, or also lifting her left leg .she did fall on Fridat evening this past week . Medical record review of a Provider Progress Note dated [DATE] revealed .night shift nurse reports patient complains of pain to right LE (lower extremity), cries out with transfers and care, report fell on Friday. Pt very confused with dementia, unable to answer ROS (review of symptoms) question. She does however cry out and grimace in pain with passive ROM (range of motion) of right LE, at hip and knee. X-ray ordered. NWB (non weightbearing) until resulted. Highly suspect fracture d/t (due to) pt response to movement and her overall withdrawn mood today. Pt usually restless and trying to ambulate, mildly agitated and constantly busy; staff frequently engaged in distracting and occupying pt with conversation, folding linens, drawing, etc. Today she is very quiet and withdrawn, no attempts to get out of WC (wheelchair) observed . Medical record review of a Provider Progress Note dated [DATE] revealed .Patient seen for abnormal x-ray. Patient fell over the weekend Patient originally was not found to have any injury. However, she became progressively more in pain when trying x-ray of the hip was done and showed acute fracture. Patient sent to hospital for further evaluation by orthopedics . Review of facility investigation of a statement from Nurse Practitioner (NP) #1, revealed .I was called to see the patient (Resident #1) on [DATE] related to lethargy and vomiting. I ordered abdominal x-ray, blood work, and neuro checks because she did have a recent history of a SDH (subdural hematoma) I felt the most likely rationale for her symptoms was slight oversedation from [MEDICATION NAME] plus [MEDICATION NAME]/[MEDICATION NAME]. The abdominal film and blood work were within normal limits. She then had a fall on [DATE] and was not immediately found to have any injuries from nursing staff. On the night of the 25th/morning of the 26th nursing notes she was having pain and difficulty turning so this prompted an x-ray. This did reveal an assumed acute fracture on the right hip. Her family was notified and agreed to send to the ER for prompt evaluation by orthopedics . Review of facility investigation of an undated statement by NP #2, revealed .(Resident #1) had several falls prior to admission and her dementia was made worse by [MEDICAL CONDITION] related to a pretty severe non-operative cerebral hemorrhage which occurred prior to admission. During her stay she was continually confused and disoriented, frequently agitated and trying to rise from the wheelchair, bed, or chair without any awareness of personal safety and fall risk . On (MONTH) 26th I was notified at the beginning of my work day by the outgoing night shift nurse the patient was crying out in pain with transfers and personal care, especially when the right lower extremity was moved. On examination I found the patient sitting in a wheelchair but not her usual active, agitated self. She denied pain verbally but called out and grimaced with passive ROM exam of her lower extremities, more so on the right side. Because the patient was constitutionally changed with flat affect, withdrawn, refusing offer of drink, my suspicion of a possible [MEDICAL CONDITION] was heightened. The nurse reported she had fallen several days earlier but no visible injury or change in behavior or ROM was noted at the time of the fall. The pain in the right lower extremity seemed, from verbal reports by staff, to be a concern early that morning (26th). I ordered an x-ray of the right hip and knee. The results were give to my colleague who followed up with an exam of the patient and sent her out to the hospital for further evaluation and treatment . Review of facility investigation revealed Resident #1 was transferred from the hospital to Hospice where she expired on [DATE]. Review of the Death Certificate from the Medical Examiner revealed the cause of death was acute right femur fracture; the contributing cause was acute on chronic left subdural hematoma; and the death was accidental. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM in the conference room revealed Resident #1 had a fall on [DATE]; the nurse assessed her; and Resident #1 was determined to have no injury. Continued interview revealed Resident #1 was assisted to bed without problem. Further interview revealed on [DATE] the night nurse discovered Resident #1 was in increased pain which was reported to the NP and an x-ray was ordered. Continued interview revealed the DON talked to all staff who cared for Resident #1 from [DATE] - [DATE]. Further interview revealed Resident #1 complained of nausea and vomiting on [DATE] and the NP assessed her, concerned the subdural hematoma was extending. Continued interview revealed the NP ordered labs and neuro checks to assess any changes. Further interview revealed Resident #1 received Tylenol Arthritis three times daily and did not required any additional pain medication from [DATE] - [DATE]. Continued interview revealed Resident #1 had [MEDICAL CONDITION] and the NP questioned whether the resident sustained [REDACTED]. Further interview the DON confirmed Resident #1 was not supervised adequately to prevent a fall.",2020-09-01
694,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,272,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to comprehensively assess 1 resident (#153) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED].condom catheter prn (as needed) for [MEDICAL CONDITION] per patient request; diagnosis-[MEDICAL CONDITION]. Further review revealed this order was discontinued on 3/3/17. Interview with Certified Nurse Aide #1 on 6/7/17 at 10:25 AM on the third floor near the resident's room revealed the resident did use a condom catheter and staff does provide care for the catheter as needed. Interview with the Minimum Data Set (MDS) Coordinator/Registered Nurse #1 on 6/7/17 at 5:00 PM in her office confirmed the MDS dated [DATE] did not reflect the resident's use of a condom catheter and should've been coded . for an external catheter. Interview with Resident #153 on 6/7/17 at 6:00 PM in the resident's room revealed the resident did use a condom catheter. The resident stated he applied the condom catheter himself as needed. Continued interview with Resident #153 revealed when needed the staff will empty the catheter bag and sometimes he will empty it.",2020-09-01
695,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,280,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the comprehensive care plan to reflect a low bed and fall mat intervention for 1 Resident (#216) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #216 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Continued review revealed the resident required limited assistance of 1 person for bed mobility, transfers, walking in the room, corridor, locomotion on and off the unit, and toileting. Medical record review of a Falls Risk assessment dated [DATE] indicated the resident was at risk for falls. Medical record review revealed Resident #216 had a fall 3/9/17. Continued review revealed an intervention in place prior to the fall was bed in low position. Medical record review revealed Resident #216 had a fall on 3/18/17. Continued review revealed the immediate intervention put into place after the fall was initiated low bed. Medical record review revealed Resident #216 had a fall on 3/19/17. Continued review revealed, .bed was lowered to lowest and locked .floor mat is in place . Medical record review of a comprehensive care plan dated 3/8/17 and revised 4/7/17 revealed a problem of .Patient is at risk for falls (related to) dementia with [MEDICAL CONDITION] and behaviors/agitation, use of (medications) that can increase risk, (End Stage [MEDICAL TREATMENT]) with recent (Mental Status) change .and (history) of fall since admission . Continued review revealed there was no intervention for a low bed or a fall mat on the care plan. Interview with the Director of Nursing on 6/7/17 at 3:50 PM in the Fine Dining Room confirmed the facility failed to update the care plan to reflect a low bed and fall mat intervention for Resident #216.",2020-09-01
696,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,281,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an order was obtained for the use of a condom catheter for 1 resident (#153) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Further review revealed this order was discontinued on 3/3/17. Interview with Unit Manager/Registered Nurse (RN) #1 on 6/7/17 at 1:42 PM on the third floor at the nurses station confirmed there was no order for a condom catheter for the resident. RN #1 stated the resident did use a condom catheter and had it on this morning . Interview with Resident #153 on 6/7/17 at 6:00 PM in the resident's room revealed the resident did use a condom catheter. The resident stated he applies the condom catheter himself as needed. Resident #153 said when needed the staff will empty the catheter bag and sometime he will empty it.",2020-09-01
697,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,318,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical reocrd review, observation, and interview, the facility failed to provide services to prevent further decrease in range of motion for 1 Resident (#105) of 26 residents sampled. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a notation of discharge from a restorative dining form dated 7/27/10 revealed the resident could feed self with staff set up. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief interview for Mental Status was not completed related to the resident was rarely/never understood. Medical record review of a progress note dated 2/14/17 revealed the resident was .contracted . (a fixed condition preventing stretching of a muscle) in both arms with the left wrist .worst than other areas. Medical record review of a significant change MDS dated [DATE] revealed Resident #105 required extensive asistance of two people for bed mobility, dressing, toileting, and personal hygiene. Continued review revealed the resident had limited range of motion to both arms. Medical record review of a case conference summary dated 4/12/17 revealed .changes in functioning ability are patient is nonverbal, contracted, bedbound . Medical record review of a care plan revised on 4/25/17 revealed .Patient requires assistance with ADLs (Activities of Daily Living) and/or functional mobility . an intervention for active and passive range of motion to extremities during care as tolerated. Medical record review of a progress note dated 6/6/17 revealed .extremities contracted Observation on 6/6/17 at 9:17 AM in the resident's room revealed Resident #105 in bed, the resident's left arm was bent at the elbow and the left wrist was curled toward Resident #105's chest. There was no supportive device for the resident's arm. Observation on 6/7/17 at 8:11 AM in the resident's room revealed the resident was in bed, the left arm was bent at the elbow and the left wrist was curled toward the resident's chest. There was no supportive device for the resident's arm. Interview with Licensed Practical Nurse (LPN) #2 on 6/7/17 at 9:17 AM in the hallway near the resident's room confirmed the resident had contractures to the left arm. Continued interview confirmed the resident did not currently receive physical therapy or restorative therapy and did not use supportive devices. Interview with Certified Nursing Assistant (CNA) #1 on 6/7/17 at 10:02 AM in the hallway revealed the CNA had a permanent assignment to care for the resident. Continued interview revealed the CNA had cared for the resident for aproximately 6 months. Further interview revealed the CNA was aware the resident had limited movement of both arms. Continued interview revealed the CNA had not received instructions on range of motion and did not provide range of motion to the resident. Interview with LPN #1 on 6/7/17 at 10:20 AM at the 3rd floor nurse's station revealed the nurse was familiar with Resident #105. Continued interview confirmed the resident was not receiving physical therapy or restorative services. Further interview revealed in the past the facility used towels or stuffed animals to support the arms or legs of a resident having limited mobility however this was not currently being done for Resident #105. Interview with Nurse Practitioner #1 on 6/7/17 at 12:30 PM in the Assistant Director of Nursing's (ADON) office revealed the resident was receiving palliative care. Continued interview revealed the Nurse Practitioner did not know when the resident had declined. Further interview confirmed range of motion was appropriate for Resident #105. Interview with the ADON on 6/7/17 at 12:30 PM in the ADON's office revealed range of motion was an appropriate intervention for Resident #105. Further interview revealed staff were expected to provide range of motion during care. Continued interview revealed no evidence the staff provided range of motion to the resident. Further interview confirmed the facility failed to provide range of motion to Resident #105's arms to prevent further decrease in motion.",2020-09-01
703,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,773,D,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to identify 1 of 33 residents (#55) prior to obtaining laboratory services. The findings include: Review of facility policy, Laboratory and Diagnostic Test Results-Clinical Protocol, dated 9/2012, revealed .The staff will process requisitions and arrange for tests . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating resident was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Medical record review of the physician's orders [REDACTED]. Medical record review of an Event Report dated 5/31/19 with a completion date of 6/11/19, revealed .Lab drawn in error x 2 . on Resident #55 on 5/31/19 and 6/3/19. Interview with Resident #55 on 6/11/19 at 10:45 AM in the resident's room revealed serum lab tests were drawn twice from her left arm in the last 1-2 weeks without a physician's orders [REDACTED].it bothers me . and the phlebotomist did not ask for her name. Continued interview revealed she questioned her nurse on 6/3/19 .after the 2nd time and that's when they (facility) found out I didn't have any labs ordered . Resident #55 denied bruising or pain at the venipuncture site. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 5:00 PM at the 3rd floor nurses station revealed the Director of Nursing (DON) was notified that lab tests were drawn on Resident #55 on 5/31/19 and 6/3/19. Continued interview revealed when lab tests were ordered, the nurse entered the order into the facility electronic documentation system which generated a computerized requisition through the clinical laboratories and placed in a notebook at the nurses station for the phlebotomist. Continued interview with LPN #1 revealed the computerized Daily Log was initialed by the phlebotomist after the lab specimens were obtained. Interview with Registered Nurse (RN) #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 3:15 PM at the 3rd floor nurses station revealed once lab orders were placed in the computer system by the nurse there were electronic lab reminders at 12:15 AM, were printed by the nurse working at th time and placed in the identified lab notebook at the nurses station with the computerized requisition. Interview with the phlebotomist on 6/13/19 at 7:30 AM in the hallway on the 3rd floor revealed .the names on the door said the resident (#35) was in 'A' bed .I asked the resident (in the 'A' bed/actually Resident #55) if .name was (Resident #35) and (resident in the 'A' bed/actually Resident #55) said yes .I asked .where .armband was and .said it was in the cup .I should have found the nurse to help identify .(the resident) . Telephone interview with the Account Manager for the Clinical Laboratories on 6/12/19 at 5:35 PM confirmed a phlebotomist should check the resident's name on the door, ask for a resident's name and date of birth, or ask the resident's nurse to identify a resident before obtaining a specimen for laboratory tests. Interview with the DON on 6/13/19 at 11:15 AM in the conference room revealed it was up to the nurse entering the lab order into the computer system to change the room and bed number so the computerized Daily Log was accurate for the phlebotomist. Continued interview with the DON revealed the computer automatically generated the information for the requisition from the admission data on the resident and must be checked by the nurse with each lab order before printing the requisition for the phlebotomist. Resident #35 was admitted to room [ROOM NUMBER]-A and later moved to 320-B prior to 5/31/19 lab order. Continued interview with the DON confirmed the nurse entered lab orders on Resident #35 on 5/31/19 and 6/3/19 and failed to change the bed from 320-A to 320-B when the order was entered resulting in Resident #55 having 2 unnecessary venipunctures for unordered lab tests.",2020-09-01
704,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,849,D,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility contract review, medical record review, and interview, the facility failed to have an interdisciplinary care plan between the hospice services provider and the facility for 1 of 8 residents (#55) receiving hospice services. The findings include: Review of a facility contract, Agreement between Hospice and Facility, dated 6/12/08, revealed .Hospice will prepare a care plan for that patient within two (2) working days and deliver a copy of it to the Facility . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the Nursing Care Plan, revised 6/11/19, revealed Resident has recently elected hospice services for comfort care--please notify hospice nurse of changes in condition/comfort .Nursing staff and hospice will collaborate care of resident/services needed for resident . Medical record review of the Hospice Care Plan, dated 6/12/19, revealed .skilled nursing to assess and evaluate 6/3/19 through 6/17/19 . Interview with Hospice Registered Nurse (RN) #3, on 6/12/19 at 10:15 AM in the 3rd floor hallway revealed she assessed Resident #55 on 6/5/19 with 2 Stage 2 Pressure Ulcers. Continued interview confirmed a Hospice Care Plan was not available to the facility at this time. Telephone interview with Hospice RN #7, identified as the Clinical Director of the Hospice provider, on 6/12/19 at 5:00 PM confirmed .we communicate our assessments verbally to the facility .we always talk to the nurse in the facility .written assessments are available to be sent over on request .we place the (handwritten) note (Communication Form) in a box in the charting room to be scanned into the chart .yes our policy says 48 hours after admission we try to give the (Hospice) care plan to the facility . Interview with the Director of Nursing (DON) on 6/13/19 at 3:00 PM in the conference room confirmed the Hospice Plan of Care was signed by the Hospice Medical Director on 6/12/19, sent to the facility 8 days after the resident was admitted to the Hospice provider instead of the 2 days required by the contract agreement between hospice and the facility.",2020-09-01
705,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,693,D,0,1,ITMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation, and interview, the facility failed to administer a tube feeding formula as ordered by the physician for 1 resident (Resident #133) of 5 residents with tube feeding. Findings include: Review of the undated policy, Enteral Tube Feeding (Continuous Pump), revealed the .Procedure .Verify the physician's order .Check the label on the enteral formula against the physician order . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician order dated 6/15/18 revealed Glucerna (enteral/tube feeding for artificial nutrition) 1.2 calories at 60 milliliters per hour (ml/hr) continuous. Further review revealed the order was discontinued on 6/21/18. Further review of the physician orders dated 6/21/18 revealed Glucerna 1.2 calories at 75 ml/hr continuous. Observations on 6/25/18 at 8:37 AM and at 12:55 PM in Resident #133's room revealed a bottle of Glucerna 1.5 was available to be or was being administered. Observation on 6/26/18 at 7:43 AM revealed Resident #133 in the room and the tube feeding, Glucerna 1.5, was being administered with approximately 925 ml of the 1000 ml remaining available for administration. Observation in the resident's room on 6/26/18 at 10:27 AM, with Registered Nurse (RN) #3 present, and at 10:35 AM, with the Assistant Director of Nursing (ADON) #1 and RN #3 present, revealed the bottle of Glucerna 1.5 with 800 ml remaining in the bottle. Interview with RN #3 on 06/26/18 at 10:25 AM on the 200 hall confirmed RN #3 was assigned to Resident #133. Further interview confirmed the current physician order for [REDACTED].#133's room confirmed the tube feeding hung to be administered and had been administered to the resident was Glucerna 1.5. Further interview confirmed the facility failed to administer the ordered tube feeding. Interview with ADON #1 on 6/26/18 at 10:32 AM at the 200 nursing station confirmed the current tube feeding ordered for Resident #133 was Glucerna 1.2 at 75 ml/hr continuous. Further interview in Resident #133's room, with RN #1 present, confirmed the available tube feeding was Glucerna 1.5. Further interview confirmed the facility failed to follow the physician's order for the tube feeding.",2020-09-01
707,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,800,D,0,1,ITMM11,"Based on observation and interview, the facility dietary department failed to serve the cold food at or below 41 degrees Fahrenheit (F). Findings include: Observation on 6/25/18 at 11:22 AM revealed the resident main dining room mid-day meal trayline was in process and residents were eating. Further observation revealed banana pudding with whipped topping stored on ice on the trayline. Further observation revealed Registered Dietitian (RD) #1 obtaining 52 degrees F for the banana pudding. Observation on 6/25/18 at 11:32 AM in the dietary department revealed the resident mid-day meal trayline was in progress and 1 cart with 8 trays had been delivered to a unit. Further observation revealed RD #1 obtaining temperatures of individual servings of chicken salad at 50 degrees F, cottage cheese at 47 degrees F, potato salad at 48 degrees F, and banana pudding with whip topping at 42 degrees F. Observation on 6/25/18 at 11:42 AM in the dietary department revealed RD #1 tested the thermometer used to obtain all the food temperatures calibration and obtained the appropriate 32 degrees F. Interview with RD #1 on 6/25/18 at 11:22 AM in the resident main dining room and at 11:32 AM in the dietary department confirmed the facility failed to maintain the cold food at or less than 41 degrees F.",2020-09-01
708,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,880,D,0,1,ITMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, revealed the facility failed to store and date the nebulizer equipment for 2 of 6 residents (Resident #20 and Resident #13) with nebulizer equipment. Findings include: Review of the facility policy Respiratory Manual revised 7/14 revealed .Be sure nebulizer and tubing are labeled with date and initials . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 6/18/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg-3(2.5mg (milligram) base)/3 ml (milliter) Neb (nebulizer) Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul ([MEDICATION NAME]) Inhalation 4 times per day 7 days NEBULIZATION Dx (diagnosis): PNEUMONIA . Medical record review of the physician orders dated 4/27/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg-3 (2.5mg base)/3 ml Neb Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul Inhalation 4 times per day as needed CONGESTION NEBULIZER Dx: [MEDICAL CONDITIONS] . Observation on 6/25/18 at 9:08 AM in Resident #20's room revealed a nebulizer mask on top of the bedside dresser undated and not bagged. Observation on 6/25/18 at 11:25 AM in Resident #20's room, with Register Nurse (RN) #1 present, revealed the undated nebulizer mask and tubing was connected to the nebulizer machine. Further observation revealed the mask and tubing were found in the trash can. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 6/8/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg -2.5 mg /2.5 mL Neb Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul Inhalation 4 times per day NEBULIZATION DX: RESPIRATORY SYMPTOMS . Observation on 6/25/18 at 9:13 AM in Resident #13's room revealed an undated and unbagged nebulizer mask attached to the nebulizer machine stored on top of the bedside dresser. Interview with RN #1 on 6/25/18 at 11:27 AM at the 3rd floor nurse station confirmed Resident #13 and, Resident #20, had undated and unbagged nebulizer masks stored on top of their bedside dressers. Interview with RN #2 on 6/27/18 at 10:32 AM at the 3rd floor nurse station confirmed the nebulizer masks were to be changed out every other day and were to be stored in a clear bag. Further interview confirmed the facility failed to date and appropriately store the nebulizer tubing and masks.",2020-09-01
709,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,695,D,0,1,S4TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer oxygen (O2) as ordered for 2 residents (#65, #234) of 10 residents reviewed for O2 use of 19 residents sampled. The findings include: Medical record review revealed Resident #65 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 scored a 10 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene. Further review revealed Resident #65 received supplemental O2. Medical record review of the Comprehensive Care Plan dated 6/5/19 revealed the resident had O2 therapy related to [MEDICAL CONDITION] with the intervention of O2 via (by) nasal cannula (bnc) at 6 liters per minute (l/m) continuous. Medical record review of the physician's orders [REDACTED]. Observation of Resident #65 on 6/17/19 at 1:35 PM, in the resident's room, revealed the resident was seated in a wheelchair with O2 tubing in place. Continued observation revealed the O2 tubing was attached to a portable O2 tank affixed to the resident's wheelchair. Further observation revealed the O2 tank was empty. Observation of Resident #65 and interview with Licensed Practical Nurse (LPN) #3 on 6/17/19 at 1:37 PM, in the resident's room, confirmed the resident's O2 tank was empty. Continued observation and interview revealed LPN #3 removed the O2 tubing from the portable tank and applied the O2 tubing to the concentrator. Continued observation revealed Resident #65's O2 saturation level was 92% (percent) after the resident was placed back on the O2 concentrator. Further interview with LPN #3 confirmed Resident #65 had not received the O2 as ordered by the Physician. Observation of Resident #65 on 6/18/19 at 8:13 AM, in the resident's room, revealed the resident was lying in bed with eyes closed. Continued observation revealed the O2 concentrator at the bedside was turned on, and the O2 tubing was in the O2 cover bag attached to the concentrator. Further observation revealed the O2 was not being administered to the resident. Continued observation revealed the resident was not in acute respiratory distress. Observation of Resident #65 and interview with Registered Nurse (RN) #1 on 6/18/19 at 8:18 AM, in the resident's room, confirmed the O2 tubing was in the plastic cover bag attached to the concentrator and not on the resident. Further interview confirmed Resident #65 had not received the O2 as ordered. Interview with the Director of Nursing (DON) on 6/19/19 at 8:10 AM in the DON's office, confirmed the facility failed to administer O2 to Resident #65 as ordered by the Physician. Medical record review revealed Resident #234 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Observation of Resident #234 on 6/17/19 at 2:00 PM, in the resident's room, revealed the resident seated in a wheelchair eating lunch. Continued observation revealed the resident had O2 tubing in place and the tubing was connected to a portable O2 tank affixed to the wheelchair. Further observation revealed the O2 tank was empty. Continued observation revealed the resident was not in respiratory distress. Observation of Resident #234 and interview with Licensed Practical Nurse (LPN) #4 on 6/17/19 at 2:05 PM, in the resident's room, confirmed the resident's oxygen tank was empty. Continued observation and interview confirmed the resident had not received the O2 as ordered by the Physician. Further observation revealed the resident's O2 saturation level was 98% after the O2 was reapplied to the resident. Observation of Resident #234 on 6/18/19 at 3:10 PM, in the resident's room, revealed the resident was lying in bed without oxygen in use. Continued observation revealed the O2 tubing was lying on top of the O2 concentrator and was not within reach of the resident. Observation of Resident #234 and interview with LPN #1 on 6/18/19 at 3:20 PM, in the resident's room, confirmed the resident's O2 tubing was not in place and Resident #234 did not receive the O2 as ordered by the Physician. Continued observation revealed the resident's O2 saturation level was 92%. Observation of Resident #234 and interview with LPN #5 on 6/19/19 at 8:00 AM, in the resident's room, revealed the resident's O2 tubing was connected to a humidifier bottle (water bottle to help moisten the air) on the O2 concentrator. Continued observation of Resident #234 and interview with LPN #5 confirmed the humidifier bottle was not connected to the O2 concentrator. Further interview confirmed the O2 tubing and the humidifier bottle were not properly connected to the concentrator and the resident was not administered the O2 as ordered by the Physician. Interview with the Director of Nursing (DON) on 6/19/19 at 8:10 AM, in the DON's office, confirmed the facility failed to administer O2 as ordered to Resident #234.",2020-09-01
710,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,759,D,0,1,S4TK11,"**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 administer the correct dosage and correct medication for 1 resident (#39). The facility had a total of 2 medication errors in 35 opportunities resulting in a medication error rate of 5.71% (percent). The findings include: Review of facility policy, Administration of Medications, with an effective date of 4/24/19, revealed .All medications are administered safely and appropriately per physician order [REDACTED].>Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of medication administration with Licensed Practical Nurse (LPN) #6 on 6/18/19 at 7:40 AM, revealed LPN #6 administered Senna 8.6 mg 1 tablet; the physician's orders [REDACTED]. Continued observation revealed LPN #6 administered [MEDICATION NAME] (medication to treat seasonal allergies [REDACTED]. Interview with LPN #6 on 6/18/19 at 9:45 AM, at the East Wing nurse's station, confirmed Resident #39 received 1 tablet of the Senna and 1 tablet of [MEDICATION NAME] 10 mg. Continued interview confirmed the resident was not administered the [MEDICATION NAME] HCL 10 mg as ordered.we don't have any ([MEDICATION NAME]) to give, we are out .I gave her the [MEDICATION NAME] ([MEDICATION NAME]) in place of it so she would at least get something . Continued interview confirmed the Senna and the [MEDICATION NAME] were not administered as ordered and the [MEDICATION NAME] was administered without a physician's orders [REDACTED].>Interview with the Director of Nursing (DON) on 6/19/19 at 11:25 AM, in the DON's office, confirmed the facility failed to follow the physician's orders [REDACTED].#39 and failed to follow the facility's policy regarding medication administration.",2020-09-01
712,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,880,D,0,1,S4TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to follow contact isolation precautions for 1 resident (#46) of 1 resident reviewed for isolation precautions of 19 residents sampled. The findings include: Review of the facility policy, Transmission-based Precautions and Isolation Procedures, with an effective date of 1/30/19 revealed .Purpose .Transmission-based precautions are implemented based upon the means of transmission of an infection (contact, droplet, or airborne .in addition to standard precautions in order to prevent or control infection .Clearly identify the type of precautions and the appropriate PPE (Personal Protective Equipment) to be used .Place signage .outside the resident's room such as the door or on the wall next to the doorway identifying .precautions .instructions for use of PPE, and/or instructions to see the nurse before entering . Review of the facility policy, ,[MEDICAL CONDITION]. (Clostridioides) Difficile (infection in the colon causing diarrhea), with an effective date of 2/27/19 revealed .Alcohol-based hand rubs do not kill spore-forming organisms therefore hand washing must be done with soap and water . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #46's current Comprehensive Care Plan, revised 5/23/19, revealed .The resident has C. (,[MEDICAL CONDITION].) Difficile .CONTACT ISOLATION . Medical record review of current active Physician Orders revealed .contact isolation for [MEDICAL CONDITIONS]. every shift .order date 5/21/19 . Observation on 6/17/19 at 11:50 AM, revealed no sign outside the resident's room on the door or on the wall next to the doorway identifying precautions or instructions for use of PPE, and/or instructions to see the nurse before entering. Further observation revealed a PPE holder hanging on the resident's door with PPE (gown, gloves, masks, and shoe covers) available for use. Interview with Certified Nursing Assistant (CNA) #1 on 6/17/19 at 11:53 AM, in the A hallway, revealed the resident was on contact isolation for [MEDICAL CONDITION]. Continued interview revealed the facility does not place a sign on the resident's door regarding isolation. Interview with Licensed Practical Nurse (LPN) #1 on 6/17/19 at 11:59 AM, in the A hallway, revealed Resident #46 had a [DIAGNOSES REDACTED]. Further interview revealed if a visitor visits the resident she attempts to catch them before entering the room to let them know what PPE is needed prior to entering the resident's room. Continued interview revealed sometimes when visitors see the caddy on the door they question what it is for. Interview with LPN #1 on 6/17/19 at 12:46 PM, at the nurse's station, confirmed there was no contact isolation sign indicating isolation or see the nurse before entering the resident's room to alert visitors or staff regarding contact isolation. Observation on 6/17/19 at 1:15 PM, in the Resident #46's room, revealed a Blue Care Choices Coordinator standing at the bedside talking with the resident and no PPE had been donned (put on). Observation of LPN #2 on 6/17/19 at 1:17 PM, in the hallway at the resident's room, revealed LPN #2 entered Resident #46's room and delivered the meal tray without donning PPE. Interview with LPN #2 on 6/17/19 at 1:22 PM, in the A hallway, revealed if staff enter the resident's room and deliver a meal tray and are not touching the resident or anything soiled in the room, staff do not have to don PPE. Observation on 6/17/19 at 1:25 PM, in the hallway at Resident #46's room, revealed CNA #2 entered the resident's room to answer his call light. Further observation revealed the CNA donned gown, gloves, and mask prior to entering the room. Continued observation revealed she removed the PPE and placed it in biohazard containers in the room, exited the room, and used hand sanitizer to sanitize the hands. Observation on 6/17/19 at 1:35 PM, in the hallway at the resident's room, revealed CNA #2 re-entered Resident #46's room and the CNA donned gown, gloves, and mask prior to entering the room. Further observation revealed the CNA reached in her pocket, retrieved packets of butter and sour cream and gave them to the resident. Continued observation revealed the CNA removed the PPE and placed it in biohazard containers in the room, exited the room, and used hand sanitizer to sanitize the hands. Interview with CNA #2 on 6/17/19 at 1:50 PM, in the A hallway, revealed she was unaware that she should wash the hands with soap and water and was not aware she should not use hand sanitizer to sanitize the hands when a resident had [MEDICAL CONDITION]. Observation on 6/18/19 at 7:55 AM, in the resident's room, revealed the Minimum Data Set (MDS) LPN standing at the resident's bedside assisting with meal set up with gloved hands, and no gown in place. Observation of CNA #2 on 6/18/19 at 7:55 AM, in the resident's room, revealed the CNA assisting the resident with denture care. Further observation revealed the CNA had gloved hands and no gown in place. Interview with the MDS LPN on 6/18/19 at 8:08 AM, in the A hallway, revealed a gown had to be donned if touching anything contaminated in the room, otherwise only gloves had to be donned prior to entering Resident #46's room. Further interview revealed the resident should have a sign on his door that informs staff and visitors to see the nurse before entering the room due to contact isolation precautions. Interview with CNA #2 on 6/18/19 at 8:20 AM, in the A hallway, revealed she had been informed staff only had to wear gloves in the resident's room unless they were providing care for the resident and their clothes would likely come in contact with the resident. Interview with the Director of Nursing (DON) on 6/19/19 at 8:00 AM, in the Administrators office, confirmed staff should don gown and gloves prior to entering a contact isolation room. Further interview confirmed the facility failed to follow the contact isolation and [MEDICAL CONDITION] policy when providing care for Resident #46.",2020-09-01
716,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2018-07-11,658,D,1,1,QYTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to follow professional standards of practice for 1 resident (#49) of 30 residents reviewed for medication administration. The findings include: Review of the facility policy Administration of Medication, undated, revealed .Standard .All medications are administered safely and appropriately .Responsibility of the nursing professional: be aware of the classification, action, correct dosage, and side effects of a medication before administration .Read each order entirely . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Further review revealed Resident #49 required extensive 2 person physical assistance for all activities of daily living except eating, which required supervision and set up and personal hygiene which only required extensive assistance by 1 staff member. Further review revealed the resident experienced behaviors not directed towards others 4-6 days per week and rejected care 1-3 days a week. Continued review revealed the resident received an antipsychotic, antianxiety, and antidepressant medication for 7 of 7 days. Medical record review of a Physician's Recapitulation Order dated 10/23/17 revealed .Quetiapine (antipsychotic medication) 150 MG (milligrams) PO (by mouth) daily at bedtime [MEDICAL CONDITION] Disorder . Review of facility documentation dated 11/7/17 revealed .Resident had an order for [REDACTED]. (approximately) 2:30 PM prior to MD (physician) being called to obtain a new order to separate the dose . Telephone interview with Registered Nurse (RN) #1 on 7/10/18 at 10:16 AM confirmed .(on 11/4/17) took it upon myself to give (Resident #49) a part of her bedtime dose of (antipsychotic medication) .I gave her 50 (mg) of that (150 MG dose) around 4pm .it was too early .doctor was later contacted . Interview with the Director of Nursing (DON) on 7/11/18 at 4:10 PM, in the DON's office, confirmed the facility failed to follow professional standards of practice for medication administration for Resident #49.",2020-09-01
719,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-01-08,842,D,1,0,KGXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain complete and accurate medical record for 1 resident (#1) of 3 records reviewed. The findings include: Review of the facility policy, Medication Administration, dated 1/15/12, revealed .Medications shall be administered .as prescribed .The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving the medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident was discharged to an acute hospital on [DATE]. Medical record review of Resident #1's Pain Tool form dated 12/6/18 revealed the location of pain in right and left knees (front), pain was relieved by Tylenol 650 milligrams, effected the resident's sleep, social and physical activities/mobility, and emotions; and pain was made worse with movement and weather change. Medical record review of Physician Orders dated 12/6/18 revealed .Aspirin 81 milligrams (mg) 1 time daily for pain related to fracture, Monitor pain every shift, and Tylenol 325 mg Give 2 tablets every 8 hours as needed (PRN) for pain/fever . Medical record review of the Pain Interview form dated 12/13/18 revealed Resident #1 had occasional pain in last 5 days; pain did not make it hard to sleep; pain did limit day-to-day activities in past 5 days; intensity of pain 5 out of 10; indicators of pain/possible pain-vocal complaints; frequency with which resident complains or shows evidence of pain or possible pain-3 to 4 days; .Treatment .Received PRN pain medication-[MEDICATION NAME] 325 mg (milligrams) give 2 tablets po (by mouth) every 8 hr (hours) as needed-effective .Receive non-pharmaceutical intervention-Repositioning, Dim Light/Quiet environment, sometimes not effective (12/9, 12/10); Comments - resident has moderately cognitive impairment which can affect his perception of pain . Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had experienced occasional pain within the past 5 days of the review period which limited his day-to-day activity with an intensity of 5 out of 10. Medical record review of the 12/2018 Daily Skilled Charting forms regarding Resident #1's complaints of pain revealed the following: 12/8 at 1:48 PM D (Days) .Describe pain .Bilateral legs and lower back; Received PRN pain medication or was offered and declined; and Comments- Has order for Tylenol 650mg, no relief noted, placed on MD (Medical Doctor) communication book for 12/9/18 . Review of the MD communication book on 12/8/18 revealed no documentation regarding pain for Resident #1. 12/8 at 6:14 PM [NAME] (Evening) . Describe pain .BLE/Back (Bilateral Lower Extremities/Back); Received PRN pain medication or was offered and declined . 12/9 at 11:19 AM D .Describe pain .Bilateral Lower Extremities, greater to knees, low back; Received PRN pain medication or was offered and declined; Comments-MD aware . 12/10 6:34 PM [NAME] .Describe pain .in BLE, back; Received PRN pain medication or was offered and declined . 12/11 at 7:50 PM [NAME] .Describe pain .BLE; Received PRN pain medication or was offered and declined . 12/12 at 6:18 PM [NAME] .Describe pain .BLE, lower back; Received PRN pain medication or was offered and declined . Medical record review of the 12/2018 MAR revealed the Aspirin was administered daily as ordered and the pain was monitored every shift. The pain level was zero except for 12/8/18 at 9:00 AM when it was 5 out of 10. The PRN Tylenol was administered on 12/6/18 at 11:06 PM and on 12/12/18 at 12:38 PM. The level of pain monitored every shift revealed on 12/6/18 at 11:06 PM was 7; on 12/8/18 was 5 for day shift, 6 for evening shift, 2 for night shift; on 12/9/18 was 4 for day shift, was 5 for evening shift; and on 12/11/18 was 4 on evening shift. Interview with Licensed Practical Nurse (LPN) #2/Nurse Supervisor on 1/8/19 at 9:55 AM by the nursing station when asked if the Daily Skilled Charting form had the resident complaining of pain and PRN pain medication was administered what was the LPN's expectation of documentation in the MAR. The LPN stated she would .expect the MAR to indicate the PRN pain medication was administered . Further interview at 10:25 AM in the conference room confirmed the MAR failed to address the administration of the PRN medication when compared to the Daily Skilled Charting forms dated 12/8/18 to 12/12/18. Interview with the Director of Nursing (DON) on 1/8/19 at 10:10 AM in the conference room stated her expectation of .staff was to initial the MAR when a medication was administered . When asked if the Daily Skilled Charting form stated the resident was complaining of pain and the PRN pain medication was administered would she expect the MAR to reflect the administration, the DON stated Yes.",2020-09-01
720,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,157,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to obtain a discharge to hospital order for 1 resident (#4) of 30 residents reviewed and failed to obtain a physician order for [REDACTED]. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 1/16/17 revealed Resident #4 was transferred to the hospital for pain. Medical record review revealed no physician order to transfer the resident to the hospital. Further review revealed a physician order dated 1/18/17 .Return from hospital . Interview with Licensed Practical Nurse (LPN) #4 on 2/14/17 at 9:04 AM in the conference room confirmed the facility failed to obtain a physician order for [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 2/13/17 at 11:00 AM and on 2/14/17 at 11:12 AM revealed a C-Pap mask stored on the bed side table in Resident #14's room. Medical record review of the physician orders revealed no order for the C-Pap setting. Interview with LPN #3 on 2/15/17 at 8:12 AM at the nursing station revealed the staff turned the machine on and off per the direction of the resident and gave him the mask to put on. Further interview confirmed the facility failed to obtain the C-Pap setting order.",2020-09-01
721,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,225,D,0,1,BNS411,"**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 report allegations of abuse in a timely manner for 3 residents (#20, #31, #102) of 5 residents reviewed for abuse and failed to complete a thorough investigation for an injury of unknown origin for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment on 11/21/16. Review of a facility investigation dated 12/15/16 for Resident #20 revealed the resident was sitting at the nurse station complaining of left knee pain. An X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not contain any statements from the resident or staff providing care to the resident. Further review revealed there was no determination as to the cause of the fracture. Further review revealed the facility reported the injury of unknown origin to the State Agency on 12/21/16. Interview with the Administrator on 2/16/17 at 8:10 AM in the Conference Room confirmed she was notified of a fracture to Resident #20's left leg on 12/15/16. Continued interview confirmed the facility reported the injury to the State Agency on 12/21/16. The Administrator confirmed the facility failed to report an injury of unknown origin in a timely manner. Medical record review of a DXA Bone Density Axial Radiological Scan dated 8/15/16 revealed, .Hip data indicate [MEDICAL CONDITION] . Medical record review revealed Resident #20 received Aqua Therapy through a research program at a University, and Restorative Nurse Aide (RNA) range of motion services in 11/2016 and 12/2016 prior to obtaining the distal femur fracture. Medical record review of a Nursing Progress Note dated 12/15/16 at 5:31 PM revealed, .X-ray of left knee . No other documentation was present as to why the X-ray was ordered, or the symptoms of Resident #20. Medical record review of a Radiology Report dated 12/15/16 at 9:20 PM revealed, .Conclusion: Impacted distal femur fracture . Interview with Resident #20 on 2/16/17 at 9:50 AM in the fine dining room revealed he attended Aqua Therapy at a university on Mondays and Wednesdays. The resident stated on a Tuesday (12/13/16) RNA #1 was doing stretching exercises on his legs and he heard a pop when his left leg was raised. The resident denied pain at that point. The resident told RNA #1 his leg was dead, and he couldn't raise it at all anymore. The next day (12/14/16) he went to Aqua Therapy and wasn't able to do any therapy. Resident #20 reported his leg began to swell and have pain later that evening and the next day. The next day (12/15/16) the resident received an X-ray and found out he had a fracture. Continued interview confirmed the only people who asked him about the fracture were the Nurse Practitioner (NP), the MD ( Medical Doctor), the Physical Therapist (PT) and the Occupational Therapist (OT). Resident #20 denied any interview with facility administration following the fracture. Medical record review of a Follow Up Question Report dated 12/1/16-12/31/16 regarding how well Resident #20 tolerated the exercise activity provided by the RNA revealed the resident tolerated the exercises well on 12/11/16, 12/12/16, and 12/13/16. Telephone interview with the NP on 2/16/17 at 11:39 AM revealed she found out about the research study for Resident #20 based on his request. The NP confirmed the MD was aware of the research program based on the information she provided and was aware of the results of the bone density scan with a [DIAGNOSES REDACTED]. Telephone interview with the MD on 2/16/17 at 12:15 PM confirmed he was in agreement with Aqua Therapy research therapy and was aware of the potential risks to the resident related to the bone density results. The MD stated, We treated him with [MEDICATION NAME] (medication used to prevent and treat bone loss) for a year first. In hindsight, it probably wasn't the best thing to do but I would do it again. The MD confirmed he had frequent conversations with the NP regarding the therapy and did see improvement with the resident's function prior to the fracture. When asked what the cause of the femur fracture was, the MD stated, Really, really severe [MEDICAL CONDITION] and he was functionally not capable of weight bearing activity. Interview with the Administrator on 2/16/17 at 12:15 PM in the Administrator's office confirmed the facility investigation report was incomplete. Continued interview confirmed the facility did not interview the resident, other staff members who had contact with the resident between 12/13/16 and 12/15/16 or obtain statements from them. The Administrator confirmed there was no determination of the cause of the fracture and confirmed the facility failed to complete a thorough investigation for an injury of unknown origin for Resident #20. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation revealed Resident #31 was observed with a pink, swollen .left hand pinky finger . on 1/2/17 at 11:30 AM in the main dining room. Further review revealed the cause of the swelling and discoloration was unknown and the facility initiated an investigation. Review of a facility investigation revealed the facility reported the injury of unknown origin to the State Agency on 1/9/17, 8 days after the incident occurred. Interview with the Administrator on 2/16/17 at 8:10 AM in the conference room confirmed the facility failed to report the injury of unknown origin to the State Agency in a timely manner. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum (MDS) data set [DATE] revealed the resident was severely impaired cognitively. Review of a facility investigation dated 1/21/16 revealed at 11:20 AM Housekeeper #1 witnessed CNA #5, .Allegedly .pulled covers off resident and cursed at him Continued review of the facility investigation revealed a written statement by Housekeeper #1 dated 1/26/17. Interview with Housekeeper #1 on 2/15/17 at 1:50 PM in the housekeeping room on the 300 Hall revealed she was cleaning in Resident #102's room on 1/21/17. She stated CNA #5 entered the room, talking trash, calling Resident #102 names, using profanity, and .jerked the cover off him . She further stated the resident appeared to look scared and hurt. She stated she reported the incident to her immediate supervisor, the Director of Housekeeping on 1/21/17. She also stated she was scheduled off work until 1/25/17. She stated on 1/26/17 she was called to Administration and asked to complete a written report of the incident. Interview with the Administrator/Abuse Coordinator on 2/15/17 at 5:00 PM in her office revealed she was made aware of the alleged abuse to Resident #102 on 1/26/17 by the Director of Housekeeping, after he returned to work following an illness. Continured interview revealed the facility failed to report an allegation of abuse in a timely manner to appropriate agencies.",2020-09-01
722,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,226,D,0,1,BNS411,"**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 it's own policy for investigating allegations of abuse for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment. Review of facility investigation dated 12/15/16 revealed Resident #20 was sitting at the nurse station complaining of left knee pain. Continued review revealed an X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not contain any statements from the resident or staff providing care to the resident. Further review revealed there was no determination as to the cause of the fracture. Interview with the Administrator on 2/16/17 at 12:15 PM in the Administrator's office confirmed the facility investigation was incomplete. Continued interview confirmed the facility did not interview the resident, other staff members who had contact with the resident between 12/13/16 and 12/15/16, or obtain statements from them. The Administrator confirmed there was no determination of the cause of the fracture and confirmed the facility failed to follow their policy regarding investigating allegations of abuse for Resident #20.",2020-09-01
726,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,412,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide dental care for 1 resident (#71) of 30 residents reviewed. The findings included: Medical record review revealed Resident #71 was admitted to the facility 6/1/15 with [DIAGNOSES REDACTED]. Observation and interview with the resident on 2/14/17 at 2:52 PM, in the resident's room revealed the resident had no natural lower teeth and an upper denture plate. Interview with Resident #71 revealed she lost her lower denture plate and had told the staff she wanted to see a dentist but had not seen one. Continued interview with Resident #71 revealed her roommate had seen a dentist but she had not. Interview with the Social Worker (SW) on 2/15/17 at 9:50 AM in the Social Services office confirmed the resident had been scheduled to see the dentist on 10/27/16, however, the appointment was canceled by the Dentist's office due to incomplete paperwork. Continued interview revealed the SW confirmed the facility failed to provide dental care for Resident #71.",2020-09-01
728,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,578,D,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain accurate advanced directives (code status) in the electronic medical record for 1 of 42 sampled residents (Resident #86) reviewed. Findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the electronic medical record for Resident #86 on [DATE] at 4:10 PM and [DATE] at 9:50 AM revealed the resident's advanced directive (codes status) was Cardiopulmonary Resuscitation (CPR) indicating she preferred life saving interventions if she has no pulse and is not breathing. Medical record review of Resident #86's hard chart revealed a POST (Physician order [REDACTED]. Interview with the charge nurse, Licensed Practical Nurse (LPN) #5 on [DATE] at 9:50 AM at the nurses station after viewing Resident #86's, home page on the electronic medical record and the hard chart copy of the POST form confirmed the electronic medical record and hard copy POST form were not the same. Further interview confirmed the hard copy POST form was the correct document to follow. The LPN (#5)confirmed the facility failed to maintain accurate code status for Resident #86 in the electronic medical record.",2020-09-01
731,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,641,D,0,1,24XE11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess the use of insulin on the Minimum Data Set (MDS) for 1 of 42 sampled residents (Resident # 50) reviewed. Findings include: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] for Resident #50 revealed the resident did not receive any insulin during the 7 day review period. Interview with Resident #50 on 4/16/18 at 11:27 AM in her room stated she received insulin injections daily. Medical record review of physician's orders [REDACTED]. Medical record review of the Blood Sugar Administration Record for (MONTH) (YEAR) revealed Resident #50 was administered regular and [MEDICATION NAME] as ordered from 2/1/18 - 2/28/18. Interview with Registered Nurse #2 (MDS Coordinator) on 4/18/18 at 9:40 AM in the conference room confirmed the facility failed to accurately assess Resident #50's use of insulin on the Quarterly MDS dated [DATE].,2020-09-01
735,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,758,D,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications had a 14 day limitation or prescriber documentation with medical rationale for continuation for 2 of 7 sampled residents (Resident #238 and Resident #239) reviewed. Findings include: Medical record review revealed Resident #238 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of (MONTH) (YEAR) - (MONTH) (YEAR) Medication Administration Record [REDACTED]. Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing on 4/18/18 at 6:10 PM in the conference room confirmed the facility failed to ensure PRN [MEDICAL CONDITION] medication had a 14 day limitation or documented rationale for continuation for Resident #238 and Resident #239.",2020-09-01
738,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-05-02,804,D,0,1,SHOF11,"Based on review of the resident council minutes, review of the resident posted menu, observation and interview, the facility dietary department failed to serve palatable pureed textured meat for 1 of 3 meals observed. The findings include: Review of the Resident Council Minutes dated 2/27/19 revealed 2 residents stating would like something other than chicken and goulash, meal ticket stated resident did not like pork and that was not true, would like more variety on the menu, more salads like potato salad and macaroni salad. Review of the 4/29/19 resident mid-day meal posted menu revealed Marinated Pork Chops and Gravy, Lima Beans, and Coin Carrots. Further observation revealed no therapeutic diet menu and no portion per food item specified on the menu. Observation on 4/29/19 at 11:43 AM in the dietary department, with the Dietary Supervisor present, revealed the resident mid-day meal trayline was in operation. Further observation revealed the trayline included Pork in Gravy, Lima Beans, Mashed Potatoes and Carrots. Further observation revealed pureed foods on the trayline. Continued observation revealed the pureed textured diets received pureed meat with gravy, mashed potatoes with gravy, and pureed carrots. Further observation revealed the 2 surveyors and the Dietary Supervisor tasted all foods on the tray line including the pureed textured foods. The pureed meat tasted like bread and the meat was not able to be determined. Interview with the cook/server on 4/29/19 at 11:57 AM at the dietary department trayline when asked what the meat was in the pureed meat stated .breaded chicken tenders with bread added . When the cook/server was asked why the pureed meat was not pork as listed on the posted and cooks menus, the cook/server stated .a lot of them (residents) don't like pork . Interview with the Dietary Supervisor on 4/29/19 at 11:59 AM in the dietary department when asked how he would describe the taste of the pureed meat confirmed it .tastes like bread .",2020-09-01
739,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-02-28,600,D,1,0,VR3611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview the facility failed to intervene and protect from abuse 1 (#2) of 4 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 1/19/18 Quarterly Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 of 15. 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 cognitively intact with a BIMS score of 15 of 15. Review of the facility investigation revealed on 1/28/18 Resident #1 and Resident #2 were together outside of the Bedford Corner dining room. Continued review revealed staff heard Resident #2 state loudly Resident #1 was going to hit (Resident #2). Continued review revealed three staff, including Certified Nurse Assistant (CNA) #1 rushed to reach Resident #1 and Resident #2 to separate them. Further review revealed Resident #1 struck Resident #2 in the chest/upper arm area 3 times before the staff reached Resident #1 and #2. Continued review revealed Resident #1 and Resident #2 were examined for injury and Resident #2 was found to have a hand print mark on her right breast. Interview with CNA #1 on 2/27/18 at 5:05 PM at Nurse Station 1 revealed she had witnessed the altercation between Resident #1 and Resident #2 on 1/28/18. Continued interview revealed CNA #1, just prior to the altercation, had walked through the Bedford Corner dining room and observed and heard Resident #1 and Resident #2 bickering. Continued interview revealed CNA #1 had told Resident #1 and Resident #2 to stop bickering and to separate from one another. Continued interview revealed she left Resident #1 and Resident #2 before ensuring they had separated and she continued down the hallway. Continued interview revealed she heard Resident #2 state Resident #1 was trying to hit (Resident #2). Continued interview revealed she turned and saw Resident #1 strike Resident #2 three times before staff could separate the two residents. Interview with the Director of Nursing (DON) on 2/28/18 at 8:45 AM in the conference room revealed the staff was expected to immediately separate residents who were engaged in any type of altercation. Continued interview confirmed CNA #1 failed to separate Resident #1 and Resident #2 when she witnessed the two residents arguing. Continued interview revealed the facility's failure to separate Resident #1 and Resident #2 resulted in failure to protect Resident #2 from physical abuse from Resident #1.",2020-09-01
740,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,726,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to show nursing competency in medication administration documentation for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
741,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,755,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for controlled substances for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Telephone interview with the Pharmacist on 6/25/19 at 10:23 AM confirmed an audit done by the Pharmacist, the DON, and the ADON revealed some nurses were sporadic in making entries appropriately and timely to the MAR. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
742,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,609,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to report a suspicion/allegation of abuse to the administrator for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .Abuse Reporting .This facility will not tolerate abuse .by anyone, including staff members .All alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator .the person(s) observing the incident of resident abuse or suspected resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Identification .Employees are required to report any incident, allegation or suspicion of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors will immediately inform the Administrator or in absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment. Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed staff had written statements or responses to questionnaires regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of the facility documentation included the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the facility documentation included the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the facility documentation included thestatement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with the Administrator on 9/25/8 at 11:15 AM in the conference room when asked if (RN #2) was to report the allegation/suspicion of abuse alleged involving Resident #1 on 9/16/18 to the Administrator or designee, the Administrator stated .should have been reported to me the morning of 9/16/18 .",2020-09-01
743,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,610,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to thoroughly investigate a suspicion/allegation of abuse to the Administrator or designee for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Medical record review of the Physician Orders revealed the following: From 6/23/18 to the present [MEDICATION NAME] HCL ER ([MEDICATION NAME]-antidepressant) 150 milligrams by mouth 1 time a day for depression. On 8/13/18 [MEDICATION NAME] ([MEDICATION NAME]-antianxiety) 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Discontinue [MEDICATION NAME] 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Restore [MEDICATION NAME] back to 1 milligram by mouth three times daily, note in chart GDR (Gradual Dose Reduction) failure. On 8/20/18 [MEDICATION NAME] 1 milligram by mouth three times a day related to anxiety disorder. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed the medications noted above were administered as ordered. Behavior monitoring for the antianxiety mediation was done every shift with no documentation of a behavior during (MONTH) and (MONTH) (YEAR). Medical record review of the physician orders dated 9/12/18 revealed .Check UA (urinalysis) . Medical record review of the Urinalysis, Culture and Sensitivity laboratory results dated [DATE] the UA revealed .SL (slightly) cloudy .Many Bacteria . indicating possible urinary tract infection. Further review revealed on 9/15/18 the Culture and Sensitively result .Escherichia Coli (EColi) and Extended Spectrum B-Lactamase (ESBL) . indication the resident had a urinary tract infection requiring contact isolation. Medical record review of the physician orders dated 9/13/18 revealed .Contact Isolation for ESBL until antibiotics complete . Further review of the physician orders dated 9/16/18 revealed [MEDICATION NAME] (antibiotic) 100 milligrams by mouth two times daily times 10 days for Urinary Tract Infection. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility reported an allegation of abuse occurring on 9/15/18 at 1:00 AM involving Resident #1 and a staff member. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed Resident #1 had responded to a questionnaire regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of facility documentation of the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the undated staff questionnaire completed by CNA #1 after the 9/16/18 event asking Do you know of any abuse? had NO. Review of facility documentation included the email dated 9/18/18 from CNA #2 to the facility revealed On Saturday the 15th of (MONTH) as I was giving care to (Resident #1) she was very agitated and aggressive, cursing and smaking (sic) at me refusing care and knocking her bedside table over all on table stuff was in floor (Resident #1) had been digging and playing in her bm (bowel movement) was trying to get out. Of bed I went immediately to the charge nurse (RN #2) and told her what was going on and ask the other tech (CNA #1) could she help me attend to (Resident #1) she agreed then the nurse asked us to switch patient and I did so. Further review revealed no interview with CNA #2. Review of facility documentation of the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the staff questionnaire completed by RN #2 dated 9/18/18 asking Do you know of any abuse? had NO. Review of facility documentation of the statement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Review of facility documentation of the undated staff questionnaire completed after the 9/16/18 event by CNA #3, #4, #6, and LPN #1 asking Do you know of any abuse? had NO. Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with Resident #1's daughter on 9/24/18 at 3:23 PM in the conference room revealed Resident #1 .complained of lady for past couple of weeks. Said 'she (Resident #1) didn't like her (CNA #2), (CNA #2) was rough with me, argues with me, I might have wanted something and press the call light and lady (CNA #2) comes in argues with me and turns call light off and leaves.' (Resident #1) said one night the CNA (#2) stuck her head in the door and said 'I heard you were talking about me, you need to stop talking about me.' I told Mom they don't need to be arguing with you and you not argue with them. She has dementia. This went on for a couple of weeks, then she calmed down for a week. Sunday I was here and she said '(CNA #2) slapped her and was rough with me last night . I told her 'Mom, tell me the truth, are you sure? Why would she slap you?' Mom said 'she was rough with me, I told her to stop and she slapped me. She's rough with me when she changes me and I don't like it.' I told her to tell me the truth and she said the same thing again. I told her it was Sunday and I can't do anything today. I checked her skin and there were no marks on her face. I checked her skin the next day but she bruises all the time anyway. I couldn't go by that .Mom told me was a heavy set red head .I ran into RN #1 up front .When I said a red head to RN #1 she didn't know that person name either. RN #1 said she would take care of it right now. RN #1 went to the Administrator and came back to me and the Administrator and ADON (Assistant Director of Nursing) .talked . Review of the facility documentation regarding the allegation of abuse on 9/16/18 revealed no evidence the UA was considered, the [MEDICAL CONDITION] medications adjusted in 8/2018 were considered, failed to have interview with staff on duty on 9/16/18 at 1:00 AM to 3:00 AM addressing the allegation, failed to have an interview with the alleged perpetrator and residents in the vicinity of the Resident #1, failed to have documentation of Resident #1's multiple interviews with different information, failed to have an interview with the family member reporting the allegation on 9/17/18 and clarifying the details, and failed to clarify why RN #2, CNA #1 and #2 answered No to the employee questionnaire asking Do you know of any abuse? Interview with the Administrator on 9/25/8 at 1:15 PM in the conference room when asked if the facility had the multiple interviews with the resident with different versions of the event, he stated No; if they had the staff interviews of all on duty and clarification of discrepancies, he stated No, but see where should have; if there was an interview with the reporting family member for clarification of information, he stated No; if there were interviews with residents in the vicinity of the event for information, he said No; for there was a medication review considering [MEDICAL CONDITION] medication had recently been changed, he said NO; and if the laboratory results of urinary tract infection was considered to contribute, he said NO.",2020-09-01
744,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,550,D,0,1,TEZO11,"**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 ensure dignity for 1 resident (#54) of 7 residents reviewed with urinary catheters. The findings include: Facility policy review Dignity, undated, revealed .Urinary drainage bags will be covered unless residents are in their rooms, at which time the bag will be placed so as not to be visible from the hall if at all possible . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #54's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 13 indicating the resident was cognitively intact. Continued review revealed the resident had an indwelling catheter. Medical record review of Resident #54's comprehensive care plan revealed the resident had a suprapubic catheter. Observation on 11/5/19 at 8:06 AM in Resident #54's room revealed the resident lying in bed with a catheter drainage bag not covered and visible from the doorway. Observation on 11/5/19 at 9:44 AM revealed the resident in bed with an uncovered catheter drainage bag on the right side of the bed facing the door. Observation and interview on 11/5/19 at 9:46 AM with Certified Nursing Assistant #1 in Resident #54's door way confirmed the resident's catheter drainage bag was visible from the hall and not covered with a dignity bag. Continued interview when asked the procedure for catheter drainage bag placement she stated, we turn and reposition residents every 2 hours and if they have a catheter then we place the catheter bag to whichever side the resident is turned to; I just turned her and placed her bag on her right side facing the door. Observation and interview on 11/5/19 at 9:50 AM with Registered Nurse #1 in Resident #54's room confirmed the resident's catheter drainage bag was facing the hallway and not covered with a dignity bag. Continued interview when asked what was the procedure for covering a resident's catheter bag she confirmed catheter bags are to be covered with a dignity bag at all times and I don't see one on hers. Observation and interview on 11/5/19 at 9:52 AM with the Director of Nursing in the hallway outside of Resident #54's room confirmed the resident's catheter drainage bag was not covered with a dignity bag. Continued interview she confirmed catheter bags were to be covered with dignity bags at all times; I can see hers through the crack from the door and it's not covered.",2020-09-01
745,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,658,D,0,1,TEZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to meet professional standards of practice when the facility failed to obtain a lab that was ordered for 1 resident (#11) of 28 residents reviewed. The findings include: Facility policy review, Physcian Orders-(Following Physican Orders), undated, revealed .It is the policy of the facility to follow the orders of the physician .As assessments are completed, orders will be received from the physician to address significant findings of the assessments . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of Resident #11's lab report revealed the last HbA1c was obtained on 6/4/19. Medical record review revealed Resident #11 did not have the HbA1c obtained for (MONTH) 2019 per the physicians order. Interview with the Director of Nursing on 11/5/19 at 4:15 PM in her office confirmed the HbA1c lab for Resident #11 was not obtained for (MONTH) 2019.",2020-09-01
748,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,657,D,0,1,O1CY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility documents, medical record review and interview, the facility failed to revise care plans for 2 Residents (#26 and #44) of 31 residents reviewed. The findings include: Review of an undated facility policy, Care Plan Review, revealed .all residents receive a review of the Plan of Care by the Interdisciplinary Team at least quarterly . Review of the facility's undated Daily Clinical Control Quality Improvement Meeting form revealed .care plan updates as appropriate . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via (by) percutaneous endoscopic gastrostomy peg tube ([DEVICE])@ 30 ml/hr x 22 hours/day. Turn on @ 0000 Turn off @ 2200, start [DATE] 22:00 . Medical record review of the Care Plan revealed .(resident) is NPO (nothing by mouth) and is receiving tube feedings x 20 hours with auto H2O flush per pump. He has a 16 french [DEVICE] with a 20 ml bulb. He is given [MEDICATION NAME] 2.0 @ 50 ml/hr (hour) x 22 hours turn on at 0000 turn off at 2200 (May use [MEDICATION NAME] 1.5 until [MEDICATION NAME] 2.0 available) H20 auto flush via peg tube ([DEVICE]) @ 30 ml/hr x 22 hours/day. Turn on @ 0000. Turn off @ 2200. He is monitored for residual and placement of [DEVICE] every shift and PRN (as needed) . Interview with Registered Nurse #1 on [DATE] at 5:52 PM at station 1 revealed the update of the resident Care Plans are part of the SWAT (Skin And Weight Assessment Team) team and the different departments are delegated to put in a note or change the order. Further interview confirmed the facility failed to update the Care Plan to reflect a change. Medical record review revealed the facility admitted Resident #44 on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #44's Tennessee Physician order [REDACTED].Do Not Attempt Resuscitation (DNR/no cardiopulmonary resuscitation (CPR)), limited additional interventions no artificial nutrition by tube, no intubation . Review of a physician's orders [REDACTED].DNR with limited interventions. Do not intubate. No mechanical life sustaining measures . Review of the comprehensive care plan dated [DATE] and revised on [DATE] revealed .Full Code/CPR, limited interventions, no artificial nutrition by tube, do not intubate . Interview with the Director of Nursing (DON) on [DATE] at 9:59 AM in her office revealed physician orders [REDACTED]. Further interview with the DON revealed the Minimum Data Set (MDS) Coordinator was responsible for updating the care plans. The DON reviewed the physician order [REDACTED].#44 and stated Yep it's not updated. Interview with the MDS Coordinator on [DATE] at 10:07 AM in her office confirmed physician orders [REDACTED]. Further interview with the MDS Coordinator confirmed Resident #44's care plan was not updated. She stated It should have been updated when the orders were received.",2020-09-01
749,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,693,D,0,1,O1CY11,"**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 administer the rate of a tube feeding as ordered and failed to administer the tube feeding as ordered for 1 Resident (#26) of 5 residents receiving tube feeding. The findings include: Review of an undated facility policy, Enteral Tube Medication Administration revealed, .Verify physician's orders [REDACTED]. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via percutaneous endoscopic gastrostomy (peg tube) @ 30 ml/hr x 22 hours/day Turn on @ 0000 Turn off @ 2200, start 11/21/2018 22:00 . Observation on 12/3/18 at 9:37 AM, and 3:47 PM revealed Resident #26 was administered [MEDICATION NAME] 2.0 tube feeding at 50 ml/hr instead of 40 ml/hr as ordered. Observation on 12/3/18 at 12:08 PM, 3:24 PM and on 12/4/18 at 7:46 AM revealed Resident #26 was not receiving the tube feeding as ordered from 12 AM to 10 PM. Observation and interview with Licensed Practical Nurse (LPN) #4 on 12/4/18 at 4:53 PM on the station 1 hall revealed Resident #26 was receiving the tube feeding at 50 ml/hr. Further interview when asked if the enteral order was changed?, LPN #4 stated .if it had been changed they haven't changed it in the medical record . Further interview confirmed the enteral feeding order had been changed to 40 ml/hr on 11/21/18. Further interview confirmed .sometimes he's sitting out of his room and he would be off the tube feeding .",2020-09-01
750,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,758,D,0,1,O1CY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide monitoring related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 1 Resident (#4) of 27 residents receiving Anti-Psychotic medications. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] 25 milligrams (mg) by mouth twice a day . Medical record review revealed the last AIMS performed for Resident #4 was completed on 10/24/17. Interview with the Director of Nursing on 12/5/18 at 3:48 PM in her office confirmed Resident #4 did not have an AIMS completed since (MONTH) (YEAR). She stated, I know they are to be done quarterly by the nurses, we have a breakdown.",2020-09-01
751,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,550,D,0,1,BDXJ11,"Based on observation and interview, the facility failed to provide feeding assistance in a dignified manner for 1 resident (#66) of 13 residents observed during a dining observation. The findings included: Observation of lunch on 12/4/17 at 12:40 PM in the main dining room revealed Certified Nurse Aide (CNA) #1 provided feeding assistance for Resident #66. Continued observation revealed CNA #1 dropped food from the utensil onto the resident's clothing protector. Further observation revealed CNA #1 picked up the dropped food with the utensil and fed it to Resident #66. Interview with CNA #1 on 12/4/17 at 6:20 PM in the Bedford Corner room revealed CNA #1 confirmed she fed Resident #66 food dropped onto the clothing protector while providing feeding assistance. Interview with the Director of Nursing (DON) on 12/5/17 at 4:53 PM in her office revealed she expected staff to dispose of dropped food and for the food not to be fed to resident's if dropped. The DON confirmed the facility failed to provide feeding assistance in a dignified manner for Resident #66.",2020-09-01
752,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,658,D,1,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > AMENDED: Correction made to date for F658. The dates were: 12/24/17, 12/25/17, and 12/26/17. The correct dates are: 12/24/16, 12/25/16, and 12/26/16. Based on facility policy review, medical record review, and interview, the facility failed to follow physician orders [REDACTED].#439) of 14 residents reviewed. The findings included: Review of facility policy, Drug Administration General Guidelines, dated 11/2016 revealed, .Medications are administrated (administered) as prescribed, in accordance with good nursing principles and practices .At the end of each medication pass, the person administering the medications reviews the MAR (Medication Administration Record) to ascertain that all necessary doses were administered and all administered doses were documented . Medical record review revealed Resident #439 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Infuse 100 ml (900 mg) over 60 minutes at 100 ml/hr (per hour) every 24 hours times 2 weeks. Medical record review of the 12/2016 MAR indicated [REDACTED]. Medical record review of Physician's Telephone Orders dated 12/24/16 revealed, .[MEDICATION NAME] (antifungal medication) 150 mg po (by mouth) daily X (times) 3 days for yeast [MEDICAL CONDITION] . Medical record review of the 12/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/17 at 6:00 PM in the conference room confirmed the facility failed to administer [MEDICATION NAME] and [MEDICATION NAME] as prescribed by the Physician for Resident #439.",2020-09-01
755,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,758,D,0,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to monitor behaviors for 2 residents (#18, #42) of 6 residents reviewed for unnecessary medications. The findings included: Review of facility policy, Psychopharmacological Medication, dated 7/14 revealed For the purposes of this policy and procedure, the term psychopharmacological medication is defined as anti-anxiety agents, antidepressants, sedative, hypnotics, antipsychotics and other drugs that affect behavior . It is the policy of this facility to document the episodes of behaviors, the interventions attempted to alter the behavior, the impact of the medication on behavior and the presence or absence of side effects on the monthly Behavior Monitoring Form or any other approved form .Nursing will initiate the Behavior Monitoring Form, or any other approved form, for all Psychopharmacological Medications .Complete the appropriate sections every shift . Medical record review revealed Resident #18 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 #18 had received antipsychotic medication during the assessment look back period. Medical record review of a Physician order [REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review revealed no behavior monitoring for [MEDICATION NAME] was documented. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dementia, Type 2 Diabetes with Diabetic [MEDICAL CONDITIONS], Heart Failure, [MEDICAL CONDITION] Fibrillation, Heart Failure, [MEDICAL CONDITION], Dysphagia, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Gastro-[MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITIONS], Chronic Pain, Restlessness and Agitation. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #42 had received antipsychotic medication during the assessment look back period. Continued record review of the Quarterly MDS dated [DATE] revealed Resident #42 received antipsychotic medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Medical record review of the MAR from (MONTH) (YEAR) - (MONTH) (YEAR) revealed Resident #42 received the medication as prescribed. Further review revealed no behavior monitoring for [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #4 on 12/6/17 at 8:50 AM outside room [ROOM NUMBER] revealed a resident received behavior monitoring if they are prescribed antipsychotic medications. Continued interview revealed the monitoring documentation would be completed on the MAR. Interview with the Director of Nursing (DON) on 12/6/17 at 12:50 PM in the conference room revealed residents who received antipsychotic medications also received behavior monitoring. After review of the medical records, the DON confirmed the facility failed to complete behavior monitoring.",2020-09-01
757,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,580,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family member notified was not Family Member #3. Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room. The form revealed the resident's family member, specifying the relationship to the resident, was notified on 1/9/2020 at 1:15 PM. Further review revealed the family member notified was not family Member #3. Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN stated she went to the nursing station and was checking the resident's chart to initiate the notifications when the nursing station telephone rang. The LPN answered the telephone and Resident #3's relative was asking to speak to the resident. The LPN stated she noticed this family members name was listed as an emergency contact and proceeded to inform the individual of the fall and then took the telephone to the resident for the family member to talk with the resident. The LPN stated she saw the name on the list and did not recall if there was a designation of which to notify first. The LPN stated several hours later, (Named Family Member #3) called the facility and 'was yelling at me why didn't I notify her first.' The LPN stated she tried to apologize and explained what had happened regarding the telephone ringing right when she was ready to call and it was Resident #3's family on the telephone and on the emergency contact list. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed to notify the appropriate Family Member, #3. Further interview revealed the Face Sheet used at the time of the 1/9/2020 fall included the name of the the family member which called the facility but there was no evidence of the information in the current medical record or in the fall investigation documentation.",2020-09-01
758,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,641,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to accurately assess the fall on the Minimum Data Set for 1 (Resident #1) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS, [MEDICAL CONDITIONS] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named Certified Nurse Aide (CNA) #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. Further review revealed the resident's head hurt, and she had 2 hematomas to the head and was bleeding. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed Resident #1 had an unwitnessed fall with a significant injury while in another resident's room. Further review revealed the resident sustained [REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the MDS did not address the fall with injury which occurred on 12/4/2019. Interview with the Registered Nurse MDS Coordinator on 2/5/2020 at 9:20 AM in the conference room confirmed the MDS dated [DATE] failed to include the fall of 12/4/2019 by Resident #1.",2020-09-01
759,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,689,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had adequate hearing and vision with no devices; had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She did not have a change in mental status and exhibited no [MEDICAL CONDITION] or behaviors during the review period. She did exhibit inattentiveness which did fluctuate. She exhibited alteration in sleep and depression/feeling down for 12 - 14 days of the review period. She exhibited a change in energy for 7 - 12 days of the review period. She exhibited a change in appetite and concentration for 2 - 6 days of the review period. She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the care plan updated in 10/28/2019, revealed Resident #1 was at risk for falls related to she required assistance with ADLs at times, received [MEDICAL CONDITION] medication, and had Actual Falls. The interventions included .Encourage resident to request assistance in ambulating, Fall Intervention: Keep personal items within reach, activities that minimize the potential for falls while providing diversion and distraction upon her visitors departure, Make sure shower chair is locked on both sides, Provide non-skid footwear as tolerated, and Therapy to provide resident with a reacher device (long handled device with pinchers on one end to grasp items) . Medical record review of the Morse Fall Scale form dated 10/29/2019, revealed Resident #1 was at a moderate risk for falls with a score of 40. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named CNA #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side, pressure was applied with a cold towel, the other nurse called for an ambulance, which arrived and transported the resident to (named hospital) . Review of the facility investigation of the undated, Staffs 10 Questions at the Time of a Resident Fall, written by LPN #1, revealed Resident #1's head hurt, .What were you trying to do when you fell ? Walking .Position of resident when they fell ? Near wheelchair. How far from surface where they? Next to surface. What were position of their arms and legs? Arms in lap, legs in front of her .Apparel resident was wearing? Night gown .Shoes, Socks (non-skid) . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. She possibly fell from the wheelchair, unknown. The resident's head hurt, and she had 2 hematomas to the head and was bleeding. The Immediate Intervention was to apply pressure to the wounds. The resident had not had a previous fall. CNA #1 found the resident. The resident was sent to the emergency room and neurological checks were started after the resident returned from the hospital. The physician and family were notified. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed the physician and family were notified. The assigned staff to Resident #1 were CNA #1 and LPN #1. The resident had an unwitnessed fall with a significant injury while in another resident's room and was found on the floor. The circumstances were unknown. The resident sustained [REDACTED]. Review of the POS [REDACTED]. Vital Signs were - Temperature 98.4; Pulse 71; Respiration 16; and Blood Pressure 147/99. The resident was found on the floor of another resident's room and she didn't know what happened, says 'I just fell .' Fall review location: in another resident's room; location prior to fall: wheelchair; Activity at time of the fall? Unknown. Footwear/device at time of fall: shoes. There were no environmental factors identified. The immediate prevention put in place was to encourage resident to ask for assistance with ADL's. Medical record review for the Morse Fall Scale form revealed there was no form for the fall on 12/4/2019 for Resident #1. Review of the undated written statement by CNA # 1 revealed .Went down 300 hall to start my round I saw (named Resident #1) on the floor with blood around her. I immediately called for help. (Named LPN #6) and (named LPN #1) came down and we grabbed towels and applied pressure. (Named LPN #6) went and called 911 and got all the paperwork together. We took her vitals and assessed her. The paramedics showed up and picked her up . Medical record review of the potential resident witnesses to the fall of Resident #1 on 12/4/2019, revealed Resident #4's Quarterly MDS dated [DATE], showed she had a BIMS of 9, indicating she was moderately cognitively impaired (moderately range 8 - 12). She had minimal difficulty hearing, adequate vision, had clear speech and could usually make herself understood and usually understood others. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Medical record review of potential resident witness to the fall of Resident #1 on 12/4/2019, revealed Resident #5's Annual MDS dated [DATE], showed she had a BIMS of 12, indicating she was moderately cognitively impaired. She had adequate hearing and vision, clear speech, and could make herself understood and understood others. Resident #5 had another MDS dated [DATE], which showed her BIMS was 13, indicating she was cognitively intact (intact range 13 - 15) and the other data was the same as the 9/15/2019 MDS. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Further review of the investigation revealed the failure to identify the room where the fall took place, failure to identify the 2 residents in the room of the fall, and failure to obtain an interview from the residents potentially witnessing the fall, if feasible, or have data to show the 2 residents where not capable of providing information. The investigation did not include a diagram of the room layout and the resident's position at the time of the fall. The investigation included 1 witness statement, by CNA #1, who named another staff member, (named LPN #6) was present in the room. There was no statement in the investigation from LPN #6. The investigation did not include a root cause. Interview with the Interim Director of Nursing (IDON) on 2/4/2020 at 8:00 AM, in the conference room stated some areas of the Post Fall Review form addressed the fall risks assessment addressed in the Falls Management Program Guidelines policy. The IDON read the Post Fall Review dated 12/4/2019 and confirmed it did not include the fall risk assessment. Further interview at 9:10 AM confirmed the investigation did not include the statement by the staff named (LPN #6) in CNA #1's statement, did not indicate when Resident #1 was last seen by staff and what she was doing, did not include how Resident #1 got into room of the fall, did not specify the room where the fall occurred, and did not identify the 2 residents who were potential witnesses and if the 2 residents were capable of providing a statement. The IDON confirmed the investigation was not complete. The IDON confirmed the Fall Risk Assessment should have been completed as part of the investigation. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, HYPERTENSION, CHRONIC PAIN, [MEDICAL CONDITION], TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING AND ATROPHY, RETENTION OF URINE, [MEDICAL CONDITIONS], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, MAJOR [MEDICAL CONDITION], and ANXIETY DISORDER . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She had no changes in mental status, no [MEDICAL CONDITION], no [MEDICAL CONDITION] or any behaviors during the review period. The resident exhibited feeling down/depressed and a change in appetite over the past 12-14 days; a change in energy for 7-11 days, and a change in sleep and feeling bad about herself/let others down over the past 2-6 days of the review period. The resident required total 1 person assistance for bathing; extensive 2 plus (+) person assistance with bed mobility; extensive 1 person assistance with transferring, dressing, hygiene, and with toilet use. She required supervision of 1 person with locomotion on and off the unit. She resident was always incontinent of bowel and bladder. The resident had not had falls after the last MDS. Medical record review revealed the following: On 1/8/2020, of the Morse Fall Scale revealed Resident #3 score 55, indicating the resident was at high risk for falls. On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5 revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (Resident #3) lying face down on the floor. there was a fair amount of blood on floor with pt's glasses on floor in front of her. called another nurse into room, assessed pt then turned her over on her back, pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek. Pt was A&O x (alert and oriented times) 4, able to tell us what happened, denied any pain at this time. Picked her up and placed her back into her wheelchair. pt stated I was sitting on side of my bed, bent over to plug in my cell phone, and fell over. v/s (vital signs) (Blood Pressure (BP)) 134/78, (Respiration (R)) 18, (Pulse (P)) 80, O2 97% (percent) on room air. at this time bleeding to her head had stopped, contacted wound care nurse to asses for treatment, spoke to (named Nurse Practitioner). Had pt apply ice to right side of face/eye area. Will continue to monitor, continue on neuro checks per protocol. Call light within reach . Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room while bending forward trying to plug cell phone in. The roommate found the resident. The resident had an injury of a laceration above the right eye, was not sent to the emergency room , neurochecks were initiated and the physician and resident's (family member) were notified. The facility intervention was to attach the phone cord to the bedrail for easy access and the intervention was placed on the care plan. Review of the facility investigation included the undated Staff's 10 Questions at the Time of a Resident Fall form which revealed the resident stated she was 'Okay', that she was face down next to a surface and the environment was clean, dry, had no spills and the area was uncluttered. The resident was wearing pants, shirt, shoes and socks. The assistive device used was a wheelchair and she was wearing her glasses. Review of the facility investigation included the Resident Event Report Worksheet form dated 1/9/2020, written by LPN #5, revealed the date and time of the unwitnessed fall by Resident #3 was 1/9/2020 at 12:50 PM, which had occurred in Resident #3's room. The resident sustained [REDACTED]. The resident had a laceration to the right eyebrow/temple area and a red cheek. The factors related to the fall was she was reaching. The resident had no pain and the physician and family were notified. Medical record review of Resident #3's roommate, at the time of the 1/9/2020 fall, Quarterly MDS dated [DATE], revealed a BIMS score of 11, indicating she was (upper range) moderately cognitively impaired (Moderate range: 8 - 12). She had moderate difficulty with hearing, she had adequate vision and wore lenses. Medical record review of the Neurological Record form dated 1/9/2020 at 1:00 PM through 9:30 PM, and on 1/10/2020 at 1:30 AM through 5:30 AM, revealed Resident #3's results were within normal range. Medical record review of the Health Status Note dated 1/10/2020 at 9:00 AM, revealed .Nurse was called to room by (named Family Member #3). (Named Family Member #3) insisted on resident being sent to hospital for a CT (Computerized [NAME]ography) Scan due to S/P (status [REDACTED]. Noted to have bruise to right shoulder. Skin tear above right eye. No bleeding or swelling noted to site. (Named) NP (Nurse Practitioner) was called, received new orders to transport to (named hospital) for CT scan. Will continue to monitor . Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN called for help from other nurse. The LPN could not recall the name of the nurse helping her. The LPN reviewed her written report and confirmed she failed to write the name of the nurse on the report. The LPN stated once the other nurse was available, they assessed the resident. The LPN stated she notified the NP who was in the facility and the LPN recalled the NP went to assess the resident. The NP saw the resident, the vital signs and neurochecks were normal, the resident had complained of a sore head, but not pain, and the NP did not order a discharge to the hospital. Interview with the NP on 2/5/2020 at 9:35 AM, in the conference room revealed the NP had seen Resident #3 earlier in the day, prior to the fall on 1/9/2020. The NP stated she was notified of the fall, went to assess the resident, noted the neurocheck was normal so far, and the resident was not complaining of pain. The NP stated her intent was to continue monitoring the vital signs and neurochecks and to assess the resident for abnormalities. The NP stated the resident returned to the facility on [DATE] and she then wrote her note dated on 1/13/2020. Further review of the investigation revealed no written statements from the staff involved in the response, LPN #5, another unnamed nurse, the assigned CNA, the NP; failed to include what the resident was doing and last known location, prior to the fall; no statement from the resident; no statement from the roommate alerting staff of the fall; no diagram of the resident's room and the of the resident as found at the time of the fall, a complete set of the neurochecks, and no root cause analysis. Medical record review revealed the following: On 1/14/2020 at 10:48 AM, of the Infection Note revealed .Review of (Resident #3's) S/Sx (signs/symptoms) of infection completed using McGeer's Criteria. diagnosed infection: uti (urinary tract infection) Medication Order: [MEDICATION NAME]. Care plan revised as indicated . On 1/20/2020 at 3:20 PM, of the Health Status Note, written by LPN #3, revealed .Nurse was called to resident's room by therapy. Resident was sitting in floor on her bottom at the foot of her bed, with her back leaned up against heater. When asked resident what she was doing she said, I stood up and I was trying to reach my cell phone and I fell over. No complaints of pain voiced. No injuries noted. Intervention: Signage to be used to remind resident to ask for assistance. (Named NP) was notified. (Named Family Member #3) was notified .(Named Director of Nursing) was notified. Will continue to monitor . On 1/21/2020 at 8:53 AM, of the Health Status Note revealed the .IDT met to discuss resident's fall from (1/20/2020). Resident fell while in her room. Intervention is to provide resident with a sign to ask for staff assist . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #3, dated 1/20/2020, revealed Resident #3 fell on Monday, 1/20/2020 at 2:30 PM, in her room when she stood up from the wheelchair and was reaching for the cell phone and fell out of the wheelchair. The therapist found the resident on the floor. The resident had no injuries or complaint of pain. The facility's immediate intervention was to assist the resident up from the floor, with 2 staff assisting, back into the wheelchair. The recent had had recent falls and the facility started neurochecks. The physician and (Family Member #3) were notified. The intervention was signage. Review of the facility investigation included the undated, Staff's 10 Questions at the Time of a Resident Fall form, written by LPN #3, revealed Resident #3 stated she was okay, and had stood up to reach for her cell phone. The resident's position after the fall was described as sitting on her bottom with her back against the heater with her legs straight out and her arms in her lap. The environment was described as clean, dry, and uncluttered with good visibility. The resident was wearing shoes and socks with proper fitting clothing. There was no one in the area when the resident fell . Review of the facility investigation included the Resident Event Report Worksheet form, written by LPN #3, dated 1/20/2020, which revealed Resident #3 had a fall in her room while reaching which resulted in no significant injury. Further review revealed LPN #2 and CNA #2 were assigned to the resident. Interview with CNA #2 on 2/4/2020 at 1:07 PM, in the conference room revealed the CNA had been assigned to the resident but she had not witnessed the fall on 1/20/2020. CNA #2 stated she had been informed of the fall by a therapist. The therapist was working with another resident in the hallway and had walked past Resident #3's room when she saw Resident #3 on the floor. The CNA stated when she entered the room the resident was seated on her bottom with her back to the heater/air conditioner, her left side was next to the window wall, her right side was on the bed side, and her legs were straight out in front of her. The CNA asked the resident to wait to get a nurse to check her over. The CNA stated LPN #4 came to the room because LPN #2, assigned to the resident, was not available. LPN #4 assessed the resident and no injury was noted and 'we got the resident into the wheelchair.' Interview with LPN #3 on 2/4/2020 at 1:34 PM, in the conference room revealed the assigned nurse, LPN #2, had gone to lunch and she had responded to CNA #2's request to help with Resident #3. The LPN did not recall a therapist being involved. LPN #3 stated LPN #4 helped her get the resident off the floor. LPN #3 stated she called the NP and Family Member #3 regarding the fall. Interview with LPN #4 on 2/4/2020 at 1:57 PM, in the conference room revealed a therapist had walked down the hall and had said something to LPN #3, then .LPN #3 yelled for me . When LPN #4 got into Resident #3's room the resident was seated on the floor with her back to the heater/air conditioner. LPN #4 stated she and LPN #3 assessed the resident, got her up into her wheelchair, and obtained vital signs. Interview with LPN #2 on 2/4/2020 at 2:55 PM, in the conference room revealed the LPN was assigned to Resident #3 on 1/20/2020. The LPN stated .a therapist got LPN #3 in the hall, then LPN #3 or CNA #2, or someone, got me. The resident was on her buttocks with her back to the heater/air conditioner and her legs were in front of her . when the LPN got into the room. The LPN stated the resident was assessed for pain and injury, while she was on the floor, and she was okay. LPN #2 stated LPN #3 was in the room with LPN #2 but LPN #2 had no recall of LPN #4 being present. LPN #2 stated this LPN notified the NP and Family Member #3 of the fall. Further review of the investigation revealed no written statements by CNA #2, LPN #2, LPN #3, LPN #4, the NP, or the therapist seeing Resident #3 on the floor. The investigation provided failed to identify all the staff involved and failed to identify the therapist. There was no diagram of the resident's room and of the resident as found at the time of the fall, and no root cause analysis. The investigation did not include the potential of the UTI contributing to the fall. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed .to obtain interviews from staff, the therapist, anyone involved with the fall. I understand what you're saying. The information isn't there and the investigation isn't complete .",2020-09-01
760,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-03-07,602,D,1,0,V5FH11,"**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 protect a resident's right to be free from misappropriation of property for 1 resident (#3) of 10 residents reviewed. The findings included: Review of facility policy, Drug Diversion, POL 602.23, revised 11/28/17, revealed .Oncoming and off-going nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in Emergency Kits when the kit had been opened .Nurses report any discrepancies in controlled substance medication counts to the Director of Nursing Service immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies .Investigation includes but may not be limited to interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluation if loss is associated or attributed to specific individual(s), time period, unique situation or random, and identify any potential negative impact on resident's condition or safety .If potential criminal activity is suspected notify the Administrator, pharmacy manager, and consultant pharmacist at once .Educate staff on current procedures and implement interventions if needed .Document corrective action taken .Analyze findings from any discrepancy events or substantiated thefts or diversions as part of Performance Improvement . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's admission orders [REDACTED]. Continued review revealed Resident #3 brought a bottle of [MEDICATION NAME] from home. Facility investigation review revealed on 1/30/18 it was discovered 5 pills were missing from the bottle the resident brought in from home. Continued review revealed an investigation was conducted including staff interviews as well as police involvement. Further review revealed one nurse confessed she had taken the pills. Continued review revealed the nurse was terminated and the resident was reimbursed for the missing pills. Review of facility investigation revealed an interview with Registered Nurse (RN) #1 on 1/30/18 who stated she was speaking with the off-going Supervisor about the new admission (Resident #3). Continued review revealed RN #1 stated Resident #3 came in with 20 [MEDICATION NAME] pills but the Supervisor stated the resident had come in with 25 pills because she had counted them. Further review revealed both nurses went to the Narcotic box; counted the pills in the bottle; and arrived at a count of 20 pills. Continued review revealed RN #1 reviewed the narcotic sheet and it was labeled with 20 pills so she called the Administrator. Review of facility investigation revealed an interview with Licensed Practical Nurse (LPN) #2 on 1/30/18 revealed she was asked if she was the one who inventoried the pills of Resident #3 he brought from home and she said she was. Continued investigation revealed LPN #2 stated she counted 20 pills and stated LPN #1 had counted with her. Further investigation revealed LPN #2 was told the pills were counted previously and there were 25 pills but LPN #2 did not know how that was possible. Review of facility investigation revealed an interview with RN #2 who stated she counted 25 pills of [MEDICATION NAME] 10/325 mg which belonged to Resident #3. Review of facility investigation revealed an interview with LPN #1 on 2/1/18, who stated LPN #2 walked over to her chair at the nurses' station and said they had to count narcotics for the new admission. Continued review revealed LPN #1 was in the process of putting the new admission medications into the computer so pharmacy would deliver them. Further interview revealed LPN #1 saw LPN #2 with the bottle of pills but never actually saw her pour them out or physically see her count them but heard her count to 20 twice. Continued interview revealed LPN #1 never touched the pills nor did she physically see the pills. Further review revealed at this point both nurses were suspended pending the outcome of the investigation. Review of facility investigation revealed on 2/1/18 the police called the Administrator to say LPN #2 was requesting to speak with her at the police station. Continued interview revealed LPN #2 said she had done it and when asked what she had done she responded I took those pills and I'm sorry. What happens from here? Further review revealed the Administrator told LPN #2 was terminated and she would be reported to the Board of Nursing. Continued interview revealed LPN #2 was asked if she had taken any other pills and she responded This was the only time I've ever done that; I don't know what I was thinking. Review of facility investigation revealed Resident #3's personal physician as well as the Medical Director were informed of the diversion. Continued review revealed Resident #3 was informed of the situation and the facility reimbursed him for the medication. Facility investigation revealed all nurses were re-educated on narcotic counts with both nurses observing the medications and the count sheets when doing change of shift counts as well as both nurses observing and counting together when a resident brings medications from home. Interview with the DON and Administrator on 3/7/18 at 1:15 PM in the conference room revealed neither was in the facility when the diversion occurred. Review of the employee records of LPN #1 and LPN #2 revealed no previous disciplinary action for either of them.",2020-09-01
761,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,224,D,1,1,RHGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of medications for 1 resident (#79) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, released 10/20/16, revealed .Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, injuries of unknown source, and misappropriation of patient property are strictly prohibited .Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of facility policy, Drug Diversion, released 6/1/16, revealed .Oncoming and offgoing nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in E-kits (Emergency medications) when the E-kit has been opened .Nurses report any discrepancy in controlled substance medication counts to the Director of Nursing Service (DNS) immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies. Investigation included interview, medical record reviews, observation of facility practices related to handling of controlled substances; evaluate if loss is associated with or attributed to specific individuals; identify any potential negative impact on patient's condition or safety .Notify the Executive Director, pharmacy manager, and consultant pharmacist immediately .Potential theft of controlled substance is reportable to the local law enforcement agency, appropriate professional licensing board; and state agency . Medical record review revealed Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].#79 was ordered [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg (milligrams) 1 tablet QID (four times daily). Review of the Pharmacy Delivery Invoice revealed 30 tablets of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg were delivered to the facility on [DATE] and signed for by the two nurses on duty. Review of the facility investigation revealed: 1/3/17 -card of 7.5/325 mg [MEDICATION NAME] and its narcotic sheet missing -all medication carts were checked -pharmacy was called to verify delivery 1/4/17 - complete MAR (Medication Administration Records) to cart audits were done on on all carts - pharmacy was requested to do a complete audit of delivery - part of the (MONTH) narcotic shift-to-shift tracking log was also missing - interviews were completed with licensed nurses who had access to the carts - Executive Director and corporate office were notified 1/5/17 - inservices for licensed nurses on counts and drug diversion were held - police were notified - suspect nurse was terminated - suspect nurse did not show for her shift 1/4/17 at 6:00 PM - 6:30 AM nor any subsequent shifts - suspect was unable to be reached by telephone The DNS interviewed all nurses who had access to the medication cart during the period of the diversion including Licensed Practical Nurses (LPN) #5, #6, #7, #8, #9 and Registered Nurse (RN #1). Questions asked included did they count; how many medication cards did they see; did they see the card count sheet; who received the drug delivery; and what was done with the drugs after delivery. Review of the Root Cause Analysis Summary revealed the delivery of the [MEDICATION NAME] on 12/31/16. On 1/3/17 the supervisor was doing a verification of narcotics when she noted a card of [MEDICATION NAME] and its narcotic sign sheet were missing. The narcotics were signed in on delivery by 2 licensed nurses and delivered to medication carts to be locked in the narcotic drawer. The carts were kept locked and only the nurse working that hall has the key to the cart. The cards were logged onto the card count sheet. When cards were taken out of the cart they were logged on the card count sheet and nurses signed for them. Reports from pharmacy were sent to the DNS to verify narcotic deliveries and the presence of narcotics. Narcotics were delivered; accepted; and stored correctly. The nurse signed on the narcotic sheet/card count sheet as 29 vs 30 as it should have been. The nurse was made aware of the missing drug and she began to question fell ow nurses as to how it was found out. The suspected nurse became a no call no show for scheduled shifts. The suspected nurse was unable to be reached by telephone and did not return calls. The facility was unable to say definitively she was guilty but she had keys to the cart and access to the narcotics. Resident #79 had multiple cards of drugs in the cart and by changing the card count sheet with next day being a new month, the count would be correct. Interview with the DNS, on 8/2/17 at 9:25 AM in her office confirmed a card of 30 tablets of [MEDICATION NAME] as well as the accompanying sign out sheet were missing and unable to be located. The DNS also confirmed the accused nurse refused to return telephone calls so was unable to be interviewed",2020-09-01
762,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,283,D,0,1,RHGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provided a discharge summary for 1 resident (#98) of 22 discharged residents reviewed. The findings included: Medical record review revealed Resident #98 was admitted to the facility on [DATE], readmitted on [DATE], and discharged from the facility on 6/7/17 with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed the resident had no cognitive impairment. Medical record review revealed Resident #98 attended a care plan meeting on 5/10/17. Continued medical record review revealed there was no documentation of discharge planning from the facility noted during the meeting. Medical record review of a Nurse Practitioner's progress note dated 5/30/17 revealed the chief complaint was Discharge from facility. Medical record review of physician's orders [REDACTED]. Medical record review of Nursing Progress Notes dated 6/7/17 at 4:31 PM revealed, .here to transport resident to (named facility), all personal belongings sent with resident . Medical record review revealed no discharge summary could be found in the medical record or the electronic medical record for Resident #98. Interview with the Social Worker (SW) on 8/2/17 at 1:10 PM in the SW's office, when asked why there was no discharge summary in the resident's chart or explanation why the resident was discharged from the facility, the SW stated, It happened really quickly. I got a call from the daughter stating she wanted the resident sent back to (named facility). The SW confirmed there was no documentation regarding the discharge in the resident's medical record. Interview with the Director of Nursing on 8/3/17 at 4:15 PM in the Administrator's office confirmed the facility failed to complete a Discharge Summary for Resident #98.",2020-09-01
764,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-09-26,812,D,0,1,ZSR811,"**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 serve food in a safe and sanitary manner for 2 of 16 residents (#28 and #60) observed during the breakfast meal. The findings include: Review of the facility policy Dining Standards revised 11/2017 revealed .staff uses utensils, deli tissues, dispensing equipment or single use gloves to avoid bare hand contact of ready to eat foods . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 required supervision with assistance of 1 person for eating. Observation on 9/24/18 at 8:00 AM in Resident #28's room revealed Certified Nurse Aide (CNA) #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the sausage with her bare hand and placed it between the two biscuit halves and placed it back on the plate. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS assessment dated [DATE] revealed Resident #60 required supervision with meal setup only. Observation on 9/24/18 at 7:55 AM in Resident #60's room revealed CNA #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the bacon with her bare hand and placed it between the biscuit halves and put it back on the plate. Interview with CNA #1 on 9/24/18 at 8:01 AM in Resident #28's room confirmed she needed to put gloves on before touching the resident's food. Interview with the Director of Nursing (DON) on 9/25/18 at 8:22 AM in front of her office confirmed the staff needed to wear gloves when touching the resident's food.",2020-09-01
765,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,224,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of law enforcement arrest report, facility policy, medical record review, facility investigation and interview, the facility failed to ensure 1 resident (#15) of 15 reviewed was free from misappropriation of property. The findings included: Review of facility policy, Abuse, dated 10/20/16 revealed .misappropriation of patient property are strictly prohibited . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review of the Minimum (MDS) data set [DATE] revealed Resident #15 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 10/14/17 revealed Resident #15 reported a missing $60 gift card. Further review of a written statement by Licensed Practical Nurse (LPN) #6 dated 10/15/17 revealed .(Resident #15) stated that she had a $60.00 gift card stolen from her pink wristlet change purse .(Resident #15) also stated that tech (certified nurse aide) who took the card came to her room on the night of 10/14/17 after hearing that she reported a gift card stolen and tech stated 'Really (Resident #15), you borrow money off of me for weeks and then pay me back with a gift card and then report it stolen.' (Resident #15) stated she never borrowed money from the tech and she would never borrow money from a tech . Continued review of a written statement by Resident #15's sister on 10/16/17 revealed a $50 gift card was purchased on 9/19/17 and given to the resident on the same day. The resident's sister also reported the gift card had been used twice on 10/12/17 at a local store. Review of a law enforcement arrest report dated 10/14/17 revealed .We proceeded to speak with (Resident #15) who advised that she had a visa gift card missing from her change purse and presumed it had been stolen. She further advised the gift card was valued at $60.00. (Resident #15's sister) checked with the visa customer service and found that the card had been used .visa had records indicating that a total of 49.47 had been spent .A check of (local store) video footage .shows a white female making a purchase with the card number provided .A good photo (photograph) was printed and taken to the charge nurse .who recognized the lady as one of the night shift nurses .she (Certified Nurse Assistant (CNA) #7) has admitted to using the card as witnessed on video but claims she paid (Resident #15) cash for the card. To verify this statement I called (Resident #15) and she absolutely denies this ever happened .(CNA #7) showed obvious intent to deprive the owner of certain property without her effective consent. (CNA #7) was placed under arrest . Review of a written statement given to law enforcement by CNA #7 dated 10/14/17 revealed .I (CNA #7) worked on Wednesday night 10/11/12 - 10/12/12 on (the) 700 hall. (Resident #15) asked me if I would give her cash for her prepaid debit card bc (because) it wasn't a cash back card and no one would take her card and get anything for her. I told her I only had sixty dollars and she said it had fifty something on there so I gave her three twenty dollar bills and she gave me the card . Interview with the Administrator on 10/24/17 at 2:20 PM in the conference room revealed the facility investigation was neither substantiated nor unsubstantiated because she was unable to get a statement from CNA #7 and Resident #15 was reluctant to give a detailed statement. The Administrator confirmed CNA #7 was terminated due to the misappropriation of property.",2020-09-01
768,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,333,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, resident observation and interview, the facility failed to ensure residents are free of any significant medication errors for 1 resident (#12) of 13 reviewed for medications with parameters. The findings included: Review of facility policy (undated), Suggested Medication Administration, Assistance or Observation Procedures, revealed .Resident Right's and Dignity must be preserved during medication administration/observation . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order Sheet (POS) revealed an order dated 3/7/17 .[MEDICATION NAME] (Antihypertensive) 100 mg (milligram) give 1 tablet by mouth 1 time a day at 7:00 AM [MEDICAL CONDITION](Hypertension). Hold if pulse is 60 or below . Continued review of the POS revealed a second order for [MEDICATION NAME] 200 mg, give 1 tablet 1 time a day at 8:00pm for HTN, re written on 5/24/17 to include, hold if pulse is 60 or below . Medical record review of the Medication Administration Record (MAR) revealed Resident #12 received [MEDICATION NAME] 100 mg 7:AM dose and 200mg PM dose on the following dates with the pulse documented at 60 or below. 4/2/17 pulse 54, medication documented as administered. 4/9/17 pulse 60, medication documented as administered. 4/28/17 pulse 60, medication documented as administered. 6/8/17 pulse 60, medication documented as administered. 6/24/17 pulse 60, medication documented as administered. 7/22/17 pulse 60, medication documented as administered. 7/26/17 pulse 60, medication documented as administered. 7/31/17 pulse 60, medication documented as administered. 8/1/17 pulse 56, medication documented as administered. 8/2/17 pulse 60, medication documented as administered. 8/15/17 pulse 56, medication documented as administered. 8/16/17 pulse 60, medication documented as administered. 9/17/17 pulse 60, medication documented as administered. 10/15/17 pulse 60, medication documented as administered. Resident observation on 10/23/17 at 12:35 PM revealed Resident #12 sitting at bedside, call light in reach, well-groomed and dressed appropriately, conversing with roommate. Further observation on 10/23/17 at 7:45 PM revealed Resident #12 sitting at bedside conversing on the telephone. Interview with Licensed Practical Nurse #2 on 10/23/17 at 7:45 PM on the 700 hall revealed .when the pulse check of Resident #12 is 60 or below the nurse was to hold the medication . Interview with the Nurse Practitioner on 10/24/17 at 11:30 AM in the conference room revealed she .expected the nurses to follow the parameters .and was .concerned .the resident had received [MEDICATION NAME] with heart rate 60 or below .The Nurse Practitioner reviewed the MAR and confirmed the medication was given with a pulse check of 60 and below . Interview with the Medical Director on 10/24/17 at 11:10 AM on the 800 hallway revealed that he .expects the nurses to follow parameters and not to administer [MEDICATION NAME] to (Resident #12) if pulse is 60 or below. Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .the [MEDICATION NAME] was given to (Resident #12) with pulse documented at 60 and below . The DON confirmed the facility failed to prevent a significant medication error for Resident #12.",2020-09-01
769,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,431,D,1,0,KCFU11,"> Based on review of facility policy, observation, and interview, the facility failed to properly label, date, and/or discard 3 multi-dose vials of insulin according to facility policy on 1 of 4 medication carts reviewed. The findings included: Review of facility policy dated 8/31/12, Medication package insert, Medication Storage, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, revealed .facility should ensure that medications and biologicals (1) have an expired date on the label; (2) have been retained longer than manufacturers guidelines; or,(3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy .Facility should destroy or return all discontinued, outdated/expired medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law . Review of package insert for Novolin R insulin storage revealed instructions to .throw away the vial 42 days after it is taken out of the refrigerator if it is unopened . Observation of Licensed Practical Nurse (LPN) #2 during medication pass on 10/23/17 at 7:30 PM on the 700 Hall revealed 1 vial of Novolin R Insulin multi-dose vial, date opened 8/31/17. Continued observation revealed LPN #2 drew up 2 units of Insulin for Resident #16 from the vial to be administered and placed the syringe on the top of the medication cart. The surveyor advised LPN #2 the vial was expired and LPN #2 immediately discarded the syringe. Further observation of the medication cart revealed a bottle of novolin R insulin multi dose- vial opened, half full, and undated, received from the pharmacy 9/16/17, 1 vial of novalin N insulin multi-dose vial opened, undated and received from the pharmacy on 10/04/17. Interview with LPN #2 accompanied by the Director of Nursing (DON) on 10/23/17 at 8:00 PM at the 700 hall medication cart confirmed .the vial of R Insulin was expired .and the 1 vial of novolin N insulin and 1 vial of novolin R insulin were opened and undated . Interview with the DON on 10/25/17 at 3:15 PM in her office revealed the nurses are expected to label and date insulin medications when opened, discard expired medication, and check for expiration dates before administering medications. The DON confirmed the facility failed to properly label, discard and/or store medication.",2020-09-01
770,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,441,D,1,0,KCFU11,"> Based on facility policy, observation, and interview, the facility failed to follow infection control protocol for glucometer cleaning on 1 of 4 observations and facility failed to prevent cross contamination of medications, and medication cup on 1 of 25 opportunities observed. The findings included: Review of the facility policy dated 8/31/12, Cleaning Diagnostic Equipment In-Between Patients, revealed the procedure is to .clean outside of patient equipment .If no manufacturer's instructions clean with a 10% (percent) bleach solution moistened wipes in-between each patient and as needed .Allow contact with bleach solution for 1 minute .Follow with a cloth dampened with water to remove residual bleach . Further review of facility policy, General Dose Preparation and Medication Administration, Assistance or Observation revealed .The community staff should not touch the medication when opening a bottle or unit dose package . Observation of Licensed Practical Nurse (LPN) #2 on 10/23/17 at 7:40 PM on the 700 Hall at the medication cart revealed LPN #2 cleaning the glucometer without gloves and using an alcohol prep pad. LPN #2 had not used glucometer to check blood glucose level, and when asked by the surveyor how she should clean the glucometer stated .she would find out .and not use the glucometer until she found out how to clean it. Interview with LPN #2 on 10/23/17 at 7:45 PM on the 700 Hall at the medication cart revealed when asked if she knew the policy for cleaning the glucometers she said .No I don't . Interview with the Director of Nursing (DON) on 10/23/17 at 8:00 PM on the 700 Hall at the medication cart confirmed the facility failed to follow infection control protocol and cleaning of the glucometer. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 with 2 capsules and 1 tablet lying on top of medication cart surface. LPN #3 picked up the tablet with her ungloved hand and placed the tablet in the medication pouch to be crushed.Further observation revealed LPN #3 then picked up the 2 capsules with her ungloved hand off the medication cart, opened them and placed the contents into the medication pouch to be crushed. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 placed her ungloved finger into the top of the medication cup, then placed the medication into the cup. Interview with LPN #3 on 10/25/17 at 7:30 AM on 500 Hall confirmed .she should not touch medications with her ungloved hands, let medications come into contact with uncleaned surfaces, or touch other objects with gloved hands and then touch medication . Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .nursing should not touch medication or the inside of medication cups with their hands or with gloves which have been used to touch other surfaces . The DON confirmed the facility failed to follow facility policy for infection control protocol.",2020-09-01
771,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,641,D,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were conducted for residents with wander/elopement alarms for 2 of 7 (Resident #5 and #70) sampled residents reviewed with elopement risk. The findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 9/24/18 documented, .Wanderguard put on Right leg for safety precautions d/t (due to) wandering in hallways asking how to get out of this place . Medical record review of an annual MDS dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment and no use of wander/elopement alarms (wanderguard). Medical record review of the quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 7, which indicated severe cognitive impairment and no use of wander/elopement alarms (wanderguard). Medical record review of a physician's orders [REDACTED].Wanderguard in place every day and night shift for safety precautions . Observations in Resident #5's room on 7/12/19 at 10:09 AM, revealed Resident #5 had a wanderguard device on her ankle. Interview with MDS Coordinator #2 on 7/13/19 at 3:07 PM, outside the Conference Room, MDS Coordinator #2 confirmed the MDS assessments for Resident #5 dated 9/26/18 and 6/26/19 were inaccurate related to wander/elopement alarms (wanderguard). 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician orders [REDACTED].Wander guard to ankle d/t possible elopement . Medical record review of an annual MDS dated [DATE] documented a BIMS score of 3, which indicated severe cognitive impairment and no wander/elopement alarms (wanderguards) in use Medical record review of a Progress Note dated 3/13/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of Physician orders [REDACTED].Wander guard to ankle d/t possible elopement . Medical record review of the quarterly MDS dated [DATE] documented a BIMS score of 3, which indicated severe cognitive impairment and no wander/elopement alarms in use. Medical record review of a Progress Note dated 6/10/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Observations in the South Dining Room on 7/12/19 at 10:13 AM, revealed Resident #70 seated in a wheelchair coloring and he had a wanderguard device to his ankle. Interview with MDS Coordinator #2 on 7/13/19 at 3:07 PM, outside the Conference Room, MDS Coordinator #2 confirmed the MDS assessments for Resident #70 dated 2/20/19 and 5/22/19 were inaccurate related to wander/elopement alarms.",2020-09-01
774,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,690,D,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter for 1 of 1 (Resident #227) sampled residents reviewed for urinary catheters. The findings include: Medical record review revealed Resident #227 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #227's room on 7/12/19 at 8:19 AM revealed Resident #227 had an indwelling urinary catheter. Medical record review of the physician's orders [REDACTED]. Medical record review revealed there was no order for catheter care and there was no documentation of catheter care being performed. Interview with the Infection Preventionist on 7/12/19 at 2:17 PM, at the Administration Desk, the Infection Preventionist confirmed Resident #227 had the indwelling urinary catheter since admission on 7/4/19. Interview with the Staff Development Coordinator (SDC) on 7/12/19 at 2:23 PM at the Skilled Nurses' Station, the SDC was asked if there should be a physician's orders [REDACTED]. The SDC stated, Yes, there should be. The SDC confirmed catheter care should be done twice a day and as needed. Interview with the Assistant Director of Nursing (ADON) on 7/12/19 at 2:57 PM, in the ADON Office, the ADON was asked if there should be an order for [REDACTED]. The ADON stated, Once a shift and as needed. The ADON was asked if the catheter care should be documented. The ADON stated, Yes. The facility was unable to provide a physician's orders [REDACTED].#227.",2020-09-01
780,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,623,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 1 of 7 (Resident #101) sampled residents reviewed for transfer/discharge requirements. The findings included: Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Telephone/Verbal Order Signature Details documented, .Order .Send to (Named) ER (emergency room ) for eval (evaluation) and treatment .Order Date/Created Date 06/17/2018 . Review of the medical record revealed Resident #101 returned to the facility on [DATE]. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. Interview with the Social Worker on 8/21/18 at 5:55 PM, in the Social Service and Admission office, the Social Worker confirmed Resident #101 was not listed on the Emergency Transfers from Facility form that was sent to the Ombudsman for the month of (MONTH) (YEAR) and stated .we have only been notifying them of the long term residents, they (Ombudsman) told us we did not have to notify them of the skilled transfers because they were short term and this was not considered their home .",2020-09-01
781,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,690,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to ensure services were provided as ordered for documentation of intake and output (I&O) of an indwelling urinary catheter for 1 of 4 (Resident #78) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #78 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed the presence of an indwelling urinary catheter. The physician's orders [REDACTED].I&O Q (every) shift . Review of the Documentation Survey Report revealed staff failed to document the intake and output as ordered on the following dates: a. 6/1/18, 6/2/18, 6/5/18, 6/11/18, 6/14/18, 6/15/18, 6/16/18, 6/17/18, 6/18/18, 6/19/18, 6/20/18, 6/22/18, 6/24/18, 6/25/18, 6/26/18, and 6/30/18. b. 7/4/18, 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/20/18, 7/21/18, 7/22/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18 and 7/31/18. c. 8/1/18, 8/2/18, 8/4/18, 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/9/18, 8/10/18, 8/11/18, 8/12/18, 8/13/18, 8/14/18, 8/15/18, 8/16/18, 8/17/18, 8/18/18, 8/20/18 and 8/21/18. Interview with the Assistant Director of Nursing (ADON) on 8/22/18 at 1:00 PM, in the ADON office, the ADON was asked if it was acceptable not to follow the doctors order for monitor and documenting of the I&O's. The ADON stated, No ma'am.",2020-09-01
782,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,692,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for nutritional supplements for 2 of 6 (Residents #39 and 82) sampled residents reviewed for nutrition. The findings included: 1. The facility's Unintended Weight Loss policy with effective date of 6/1/11 documented, .if a resident is identified with a weight loss of 5% (percent) or more .the following interventions will be considered for implementation .3. Resident will be placed on an appropriate supplement .per dietary recommendations . 2. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #39 with moderate impaired cognition, total dependence on staff for eating, and significant weight loss. Review of the Care Plan dated 6/22/18 documented, .alteration in nutrition r/t (related to) ES (End Stage) Alzheimer's, Dementia, swallowing/chewing impairment and advanced maturation .dependent diner .6/4/18-significant weight loss .Interventions .4 oz (ounces) Ensure [MEDICATION NAME] po (by mouth) TID (three times daily) . Review of the facility's Nutrition/Dietary Note dated 6/19/18 revealed a weight of 79# (pounds) significant weight loss of 15.1% with recommendation of 4oz Ensure [MEDICATION NAME] po (oral) TID. The facility's Order Review History Report for (MONTH) (YEAR) documented, .Ensure three times a day for Supplement Ensure [MEDICATION NAME] TID .Active .order date 06/19/2018 . Review of the Medication Administration Records for (MONTH) (YEAR) through (MONTH) (YEAR) revealed the 4oz Ensure [MEDICATION NAME] TID was not administered and documented by the facility. Observations in Resident #39's room on 8/21/18 at 8:00 AM, revealed Resident #39 was being assisted with her meal by staff, she received a puree diet, with ice cream and magic cup on the tray, the resident only took a couple of sips of water. Observations Resident #39's room on 8/22/18 at 8:00 AM, revealed Resident #39 was being assisted with her meal by staff, she received a puree diet, with ice cream and magic cup on the tray. Resident #39 only consumed 25 percent (%), the staff were coaxing and cueing the resident to eat but this resident was refusing and only would drink a couple sips of water. Telephone interview with Resident #39's physician on 8/22/18 at 1:07 PM, in the conference room, the physician was asked if he was familiar with Resident #39 and her weight loss history. He stated, .yeah .she is [AGE] years .vegetative state and she is comfort measures . Telephone interview with Resident #39's physician on 8/22/18 at 2:00 PM, in the Social Worker Office, the physician stated, .her (Resident #39) weight loss is due to her age and her vegetative state . 3. Medical record review revealed Resident #82 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] assessed Resident #82 with extensive assistance from 1 staff member for eating. The Care Plan revised on 7/25/18 documented, resident has actual nutritional problem r/t (related to)[MEDICAL CONDITION]([MEDICAL CONDITION] Disease), Dysphagia, [MEDICAL CONDITION] .provide supplements as ordered: 1/20/18-4oz Glucerna po BID (twice daily) date initiated: 01/20/2018 . The facility's Nutrition/Dietary Note dated 1/20/18 documented, .He has poor oral intakes .Will start 4oz. Glucerna BID po due to suboptimal oral intakes . The facility's Order Summary Report for (MONTH) (YEAR) documented, .Glucerna 4 oz bid two times a day .Active .order date 1/20/18 . The facility's Nutrition/Dietary Note dated 3/15/18 documented, .He is offered 4 oz. Glucerna po BID due to variable intakes & gradual weight decline . Review of the Medication Administration Records for (MONTH) (YEAR) through (MONTH) (YEAR) revealed the 4oz Glucerna BID was not administered or documented by the facility. Observations in Resident #82'3 room on 8/21/18 at 12:00 PM, revealed Resident #82 was being assisted with lunch by a member, his appetite was good, and he consumed 100% of his meal. Interview with Registered Nurse (RN) #2 on 8/21/18 at 3:35 PM, at the South Hall nurses station, RN #2 was asked if Resident #82 receives any dietary supplements for weight loss. RN #2 stated, His order says Glucerna 4oz BID but I do not see it on his MAR . RN #2 was asked what time should he have received it if it was ordered BID. RN #2 stated, . 8AM and 8PM . RN #2 was then asked had he received the supplement today. RN #2 stated, He has not . Interview with Licensed Practical Nurse (LPN) #1 on 8/21/18 at 3:35 PM, at the South Hall nurses station, LPN #1 stated, It is showing up in his (Resident #82) orders but it is not on the MAR/TAR (treatment administration record) to be documented .because it is not put in to show up on there so it will not be on there . LPN #1 was asked should it have been on the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 8/22/18 at 1:48 PM, in the DON office, the DON was asked should the 4oz of Glucerna for Resident #82 be on Resident #82's MAR indicated [REDACTED]. The DON stated, Yes, ma'am it should have . The DON was then asked to review Resident #39's MARS from (MONTH) (YEAR) to present and was asked if she was aware that Resident #39 had an order for [REDACTED].No I am not (aware) .I will fix it . The DON was then asked should Resident #39 have been receiving the supplement. The DON stated, .yes.",2020-09-01
784,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,880,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 2 (Registered Nurse (RN) #1) nurses failed to ensure infection control practices were maintained to prevent the potential spread of infection during dressing change observations. The findings include: 1. The facility's Wound Care Management policy effective 5/02 and reviewed on 5/17 documented, .Remove old dressing and discard .Wash hands and apply gloves .Place bag in a red bag .Dispose of bag in BFI (biohazard) box . 2. Observations during dressing change in Resident #66's room on 8/22/18 at 9:29 AM, revealed RN #1 removed the dirty dressing and packing, failed to preform hand hygiene, and irrigated the wound with dakins solution. RN #1 packed the undermining of the wound with the [MEDICATION NAME] packing strip guiding it from the bottle with the same cotton tip applicator, then cut off the contaminated [MEDICATION NAME] packing strip with her scissors and placed them in her front pocket. RN #1 did not disinfect the scissors after use. RN #1 gathered her dirty supplies in a trash bag and placed the trash bag out in the trash bin in the hallway. RN #1 did not place the contaminated supplies in the biohazard room. Interview with the Director of Nursing (DON) on 8/22/18 at 2:13 PM, in the conference room, the DON was asked if it was acceptable not to perform hand hygiene after removing a soiled dirty dressing. The DON stated, .Absolutely not . The DON was asked where should the nurses dispose of dirty dressings. The DON stated, Use a garbage bag .take it to the biohazard room. The DON was asked if it was acceptable to place dirty dressing in the regular trash bin in the hallway. The DON stated, No. The DON was asked when she expected the nurses to clean their scissors during dressing change. The DON stated, Before .after use .with a disinfectant wipe.",2020-09-01
785,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-01-24,677,D,1,0,9MDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to provide incontinence care for 1 resident (#1) of 5 residents reviewed for incontinence care. The findings included: Medical record review revealed Resident #1, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 1/12/18. Review of the Minimum Data Set with a reference date of 10/14/17 revealed Resident # 1 was rarely or never understood. Continued review revealed he required total dependence on nursing staff for toilet use and personal hygiene. Medical record review of Resident #1's Bladder Evaluation dated 10/26/17 revealed the resident was incontinent of bowel and bladder at times. Continued review revealed he also went to the bathroom to void at times. Medical record review of the Care Plan dated 11/1/17 revealed Resident #1revealed the resident was to be toileted every 2 hours and as needed and his clothing was to be changed after each incontinent episode. Continued review revealed the resident required assistance with hygiene and showering. Interview with LPN #1 (regarding the 1/11/18 allegation by the caregiver) on 1/22/18 at 6:00 PM in the front conference room, confirmed .His brief was very very wet .Looked like he had voided more than once .His brief was really very wet. Telephone interview with Resident #1's caregiver on 1/23/18 at 4:18 PM confirmed the resident was saturated with urine on 1/9/18 and 1/11/18, when she visited the resident in the facility. Telephone interview with Resident #1's wife on 1/23/18 at 4:50 PM confirmed the resident was saturated with urine on 1/9/18, when she visited the resident in the facility. Interview with the Administrator and the DON on 1/24/18 at at 12:11 PM in the conference room, confirmed they were aware of the 1/11/18 incident with Resident #1, and staff re-education had been provided.",2020-09-01
786,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,655,D,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update a baseline care plan for 1 resident (#29) with an indwelling urinary catheter of 2 residents' baseline care plans reviewed of 27 residents sampled. The findings include: Medical record review revealed Resident #29 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 #29 was incontinent of urine and stool, oxygen dependent, and required assistance of 2 staff for transfers. Further review revealed the resident scored a 15 on the Brief Interview for Mental Status indicating no cognitive impairment. Medical record review of Resident #29's Baseline Care Plan dated 1/22/19 revealed no documentation the resident's care plan was revised to identify the resident had a urinary catheter. Medical record review of a Physician's telephone order dated 1/23/19, timed 11:20 AM, revealed .Insert FC (brand name indwelling urinary catheter) 16fr (French-denotes type of catheter)/10cc (cubic centimeters - size of balloon on tip of catheter to secure catheter placement) per patient request for comfort .Indication - DX (diagnosis) exacerbated respiratory status decline . Medical record review of a Nursing Weekly Summary dated 1/23/19 revealed, .redness on buttocks, excoriation to inner thighs, barrier cream applied .catheter put into place due to skin breakdown . Observation of Resident #29 on 1/29/19 at 10:00 AM revealed the resident seated in a high back chair in her room. Continued observation revealed the tubing for the catheter was draining clear yellow urine into a covered urinary bag. Interview with the Unit Supervisor/Licensed Practical Nurse (LPN) #1 on 1/29/19 at 3:20 PM, in the 200 Unit nursing station confirmed Resident #29's Baseline Care Plan did not indicate the resident had an indwelling urinary catheter. Interview with the Assistant Director of Nursing (ADON) on 1/30/19 at 4:10 PM, in the ADON's office confirmed the resident's skin had improved, and a long term plan for the continued use of the urinary catheter had not been determined.",2020-09-01
790,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,759,D,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to correctly administer medication for 2 residents (#3, #23) of 29 opportunities resulting in a 6.896% medication error rate. The findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Physicians order dated 12/6/18 revealed [MEDICATION NAME] (mood stabilizer) Delayed Release (DR) 125 milligram (mg) take 1 tablet by mouth 3 times daily. Observation of medication administration with Licensed Practical Nurse (LPN) #3 on 1/29/19 at 12:15 PM, outside Resident #3's room, revealed LPN #3 crushed the delayed release [MEDICATION NAME] tablet, mixed it with applesauce, and administered it to the resident. Interview with LPN #3 on 1/29/19 at 12:20 PM, in the hallway confirmed the [MEDICATION NAME] delayed release medication should not be crushed but .I can't give it whole, she may choke, she is on a pureed diet . Interview with the Unit Supervisor/LPN #1 on 1/30/19, at 3:45 PM, at the nurse's station confirmed delay released or extended release medications should not be crushed and the facility failed to notify the Physician to obtain the appropriate medication for Resident #3. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation orders dated 1/1/19-1/31/19 revealed .[MEDICATION NAME] (medication for pain) 500MG TAB (tablet) .TAKE 2 TABLETS (1000MG) BY MOUTH TWICE DAILY .8AM . Observation of a medication administration with LPN #3 on 1/29/19 at 7:37 AM, in Resident #23's room, revealed the LPN administered 1 tablet of 500 mg [MEDICATION NAME] to Resident #23. Interview with LPN #3 on 1/29/19 at 8:45 AM, at the 200 hallway nurse's station confirmed he administered 1 tablet of 500 mg [MEDICATION NAME] to Resident #23. Further interview confirmed the order was for 2 tablets to equal 1000 mg. Continued interview confirmed an incorrect dose had been administered.",2020-09-01
792,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,842,D,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate and complete medical record for 2 residents (#17, #42) of 27 sampled residents. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #17's Treatment Record (TAR) dated 12/2018 revealed .cleanse (with) NS (normal saline) and apply calcium alginate to heel daily cover (with) dry dressing . Further review revealed completion of wound care was not documented on the following dates: 12/2/18, 12/4/18, 12/5/18, 12/6/18, 12/7/18, 12/11/18, 12/12/18, 12/14/18, 12/15/18, 12/16/18, 12/17/18, 12/18/18, 12/20/18, 12/21/18, 12/23/18, 12/24/18, 12/26/18, 12/30/18, and 12/31/18 for a total of 19 out of 30 days (12/2/18-12/31/18). Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation orders dated 1/1/19 through 1/31/19 revealed .[MEDICATION NAME] (antibiotic) 1.25 GM (gram) .every 12 hours . Medical record review of a Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 1/30/19 at 3:26 PM, in the DON's office, confirmed the facility failed to maintain an accurate TAR for Resident #17 and an accurate MAR for Resident #42.",2020-09-01
800,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-06-19,561,D,0,1,S00P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to ensure 2 residents (#44, #154) received their scheduled showers of 13 sampled residents. The findings include: Review of the facility policy, Shower/Tub Bath, revised 10/2010 revealed .The following information should be recorded on the resident's medical record .The date and time the shower/tub bath was performed .The name and title of the individual(s) who assisted the resident with the shower/tub bath .Notify the supervisor if the resident refuses the shower/tub bath . Medical record review revealed Resident #44 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 had a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively intact, required limited assist of 1 for transfers, toileting and dressing, and was totally dependent on staff for bathing. Medical record review of the care plan dated 3/25/19, revealed resident has a self-care deficit with an intervention to give shower/bed bath per resident's preference as scheduled. Medical record review of the CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) FLOW RECORD dated 6/1/19-6/18/19 revealed the resident received 1 shower indicating the resident had only received 1 of 5 scheduled showers. Interview with Resident #44 during the resident council meeting on 6/18/19 at 3:00 PM, in the dining room, confirmed he had not received his scheduled showers. Interview with the Corporate Nurse on 06/18/19 at 4:10 PM, in the conference room confirmed Resident #44 had 1 shower on 6/6/19 for the month of June. Interview with CNA #1 on 6/18/19 at 4:35 PM, in the conference room confirmed there have been times, especially lately that she has been unable to complete her assigned showers. Medical record review revealed Resident #154 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 5/28/19, revealed .has potential for self care deficit .Assist with showering per schedule and prn (as needed) . Medical record review of an Activity Evaluation dated 5/28/19 revealed .Interview for Daily Preferences .how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath .1. Very important . Medical record review of an Admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident is cognitively intact. Review of a Nurse Aide Information Sheet revealed the resident prefers a shower and required the assistance of 1 staff for locomotion and transfer with a wheelchair. Review of the facility's CNA ADL FLOW RECORD dated (MONTH) 2019 revealed no showers or baths were completed from 6/7/19-6/16/19. Medical record review of the Social Services Director (SSD) notes revealed the SSD spoke with staff regarding Resident #154's shower concerns on 5/29, 5/30, 6/5 and 6/6/19. Continued review revealed on 6/6/19 the SSD spoke with the Administrator regarding Resident #154's lack of showers. Further review revealed the resident received a shower on 6/6/19, indicating the resident received 2 of the 4 scheduled showers. Interview with Resident #154 on 6/17/19 at 1:51 PM, in the resident's room, confirmed the resident had not received her scheduled showers. Continued interview confirmed the resident was able to sponge bath at the sink but was unable to wash her hair. Interview with Social Services Director on 6/18/19 at 1:25 PM, in the conference room confirmed Resident #154 wanted a female present during the shower and staff were aware of the residents request. Further interview confirmed the facility is still .missing the mark . on completing scheduled showers. Interview with the Director of Nursing on 6/18/19 at 10:55 AM, in the conference room confirmed residents should be offered a shower or bath two times a week and she was aware residents had not received all of the scheduled showers.",2020-09-01
801,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-06-19,758,D,0,1,S00P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to provide a 14 day stop date for a prn (as needed) anti-psychotic drug for 1 resident (#40) of 5 residents reviewed for unnecessary medications of 13 sampled residents. The findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/20/19. Medical record review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired. Continued review revealed Resident #40 experienced physical and verbal behaviors towards others, as well as, other behavioral symptoms not directed towards others 1-3 days of the week and required extensive to total assist with 1 staff member for activities of daily living. Medical record review of Resident #40's physician telephone order dated 3/1/19 revealed .[MEDICATION NAME] (antipsychotic medication) 5 mg (milligrams) po (by mouth) q (every) 4 (hours) prn (as needed) agitation . Continued review revealed no stop date for the medication. Medical record review of the Consultant Pharmacist Communication to the Physician dated 4/2019 revealed .Communication/Recommendation .Patient safety, and the safety of others, is a primary concern. However, PRN Antipsychotics are considered a form of restraint, and should be used only for behaviors that could be harmful to the resident or others. The most recent CMS guidelines restrict the use of PRN Antipsychotics to 14 days . Medical record review of Resident #40's Medication Administration Record [REDACTED]. Continued review revealed the resident received two doses on 3/23, 3/24, and 3/25/19. Medical record review of Resident #40's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 6/19/19 at 8:14 AM, at the nurse's station confirmed Resident #40's physician's orders [REDACTED]. Continued interview confirmed Resident #40 continued to receive 12 doses of [MEDICATION NAME] after the required 14 day stop date of a PRN antipsychotic .it should have been discontinued and reordered .",2020-09-01
802,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,557,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain a resident's dignity and respect during dressing changes for 1 of 2 (Resident #73) sampled resident's reviewed. The findings include: The facility's undated Privacy policy documented, .Privacy is also maintained during toileting, bathing and other activities . Medical record review revealed Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. The ADON exposed the resident from the waist down, exposing Resident #73's genitalia from 9:20 AM until 10:02 AM. Interview with the Director of Nursing (DON) on 5/1/19 at 11:24 AM, in the Conference Room, the DON was asked if she expected residents to be covered during a dressing change. The DON stated, We should keep the private parts covered.",2020-09-01
803,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,604,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to complete assessments before or during use of a position change alarm for 2 of 2 (Resident #63 and #346) sampled residents reviewed for physical restraints. The findings included: 1. The facility's undated RESTRAINTS policy documented, .Restraints shall only be used for the safety and well-being of the patient(s) and only after other alternatives have been tried unsuccessfully .Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Restraints shall only be used upon the written order of a physician .The order shall include .The specific reason for the restraint .How the restraint will be used to benefit the resident's medical symptom .the type of restraint, and period of time for the use of the restraint . 2. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #63's room on 4/29/19 at 11:57 AM, and 4/30/19 at 4:04 PM, revealed Resident #63 was sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Observations in the Activity Room on 4/29/19 at 2:51 PM, and 4/30/17 at 10:17 AM, revealed Resident #63 sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Interview with Certified Nursing Assistant (CNA) #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 stated, She has a pull-away (alarm) in the bed, and a pressure alarm in her chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She tends to like to stand up, and she is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. CNA #1 was asked how long the alarms would be used. CNA #1 stated, I'm not sure. 3. Medical record review revealed Resident #346 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline Care Plan dated 4/18/19 documented, .Problem Start Date .4/18/2019 .Fall Risk .Approach .Personal alarm/s to alert partners of unsafe attempts to transfer . Observations in Resident #246's room on 4/29/19 at 10:29 AM and 4:43 PM, revealed Resident #346 was lying in bed with a pull-away position change alarm in place. Observations in Resident #346's room on 4/29/19 at 11:41 AM and 12:31 PM, and 4/30/19 at 11:53 AM, revealed Resident #346 sitting in a wheelchair with a pull-away position change alarm in place. Observations in Resident #346's room on 4/30/19 at 5:01 PM, revealed Resident #346 sitting in a bedside chair with a pull-away position change alarm in place. Interview with CNA #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 confirmed she had pull away alarms for the bed and chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. Interview with the Director of Nursing (DON) on 5/1/19 at 11:17 AM, in the Conference Room, the DON was asked if any other interventions were attempted before the pull-away alarms were put in place for Resident #346 on the day of her admission. The DON stated, I think her family insisted for it to be on her. I think that was why that got put on immediately. The DON was asked if there were any assessments related to resident alarms. The DON confirmed there were no assessments. The facility was unable to provide any policies or protocols for the use of position change alarms. The facility was unable to provide assessments for the alarms before use or ongoing evaluations during use, and was unable to provide documentation for the expected duration of the alarm use.",2020-09-01
804,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,690,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 2 of 2 (Resident #22 and #73) residents with an indwelling catheter. The findings include: 1. The facility's undated Catheter Drainage System, Closed policy documented, .Never allow drainage bag to be at a level above the bladder . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed moderate cognitive impairment, total dependence on staff for all activities of daily living, and use of an indwelling urinary catheter. Observations in Resident #22's room on 4/30/19 at 11:55 AM, revealed Resident #22 lying in bed with the indwelling catheter drainage bag lying in bed beside her. Interview with the Director of Nursing (DON) on 5/1/19 at 11:12 AM, in the Conference Room, the DON was asked if it was acceptable for staff to leave the indwelling catheter drainage bag in the bed with the resident. The DON stated, .They are supposed to put it right back down. 3. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed moderate cognitive impairment, required extensive to total assistance with activities of daily living, and had an indwelling catheter. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. She placed Resident #73's bed side drainage bag on the bed with the resident from 9:20 AM to 10:02 AM. Interview with the DON on 5/1/19 at 11:25 AM, in the Conference Room, the DON was asked if a bedside drainage bag should be lying on the bed during a lengthy dressing change. The DON stated, No.",2020-09-01
805,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,698,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, [MEDICAL TREATMENT] Communication Worksheets, and interview, the facility failed to provide appropriate care and services of a resident receiving [MEDICAL TREATMENT] for 1 of 1 (Resident #60) sampled residents receiving [MEDICAL TREATMENT]. The findings include: 1. The facility's undated [MEDICAL TREATMENT] Communication policy documented, .PR[NAME]EDURE .Complete [MEDICAL TREATMENT] Communication Worksheet form a. Center (Nursing Home) nurse complete on [MEDICAL TREATMENT] days . 2. Medical record review revealed Resident #60 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] and the 60 day MDS dated [DATE] documented Resident #60 was cognitively intact and received [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] Communication Worksheet dated 4/25/19, 4/27/19, and 4/30/19 revealed the pre-[MEDICAL TREATMENT] information for Resident #60 was not completed. 3. Interview with the Director of Nursing (DON) on 5/1/19 at 10:29 AM, in the Conference Room, the DON was asked to explain the [MEDICAL TREATMENT] communication process. The DON stated, .supposed to send a [MEDICAL TREATMENT] Communication Worksheet with the resident to [MEDICAL TREATMENT] and they are to bring the form back .the pre-[MEDICAL TREATMENT] part of the sheet is supposed to be completed by the staff . The DON was asked did the facility communicate a pre-[MEDICAL TREATMENT] report to the [MEDICAL TREATMENT] center on the [MEDICAL TREATMENT] Communication Worksheets dated 4/25/19, 4/27/19, and 4/30/19. The DON stated, No .",2020-09-01
806,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,761,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely in 1 of 6 (300 Hall Medication Cart) medication storage areas. The findings include: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy dated 6/2016 documented, .Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams .by physical barrier including but not limited to baggies, storage containers, boxes . 2. Observations in the 300 Hall Medication Cart on 4/30/19 at 12:20 PM, revealed the following items in the same drawer with no separation: a. 1 container of menthol roll-on pain reliever labeled, .External use only . b. 1 container of aspirin c. 1 container of [MEDICATION NAME] d. 1 container of stool softener e. 1 container of antidiarrheal medication Observations in the 300 Hall Medication Cart on 4/30/19 at 12:24 PM, revealed the following items in the same drawer with no separation: a. 2 containers of antacid b. 1 container of eye drops c. 1 container of foot cream Interview with Licensed Practical Nurse (LPN) #1 on 4/30/19 at 12:27 PM, at the 300 Hall Medication Cart, LPN #1 was asked if external and internal medications should be stored together without a divider. LPN #1 stated, No. Interview with the Director of Nursing (DON) on 5/1/19 at 11:31 AM, in the Day Room, the DON was asked if internal and external medications should be stored side by side with no divider in the medication cart. The DON stated, No .should be separated by a divider.",2020-09-01
807,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,812,D,0,1,MD3811,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 5 of 25 (Certified Nursing Assistant (CNA) #2, Nursing Assistant (NA) #1, CNA #3, #4, and NA #2) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #29's room on 4/29/18 beginning at 12:15 PM, revealed CNA #2 touched the overbed table, positioned the table, then placed her bare hands on the Resident #29's sandwich while cutting the sandwich into 4 sections. Observations in Resident #15's room on 4/29/19 at 12:26 PM, revealed NA #1 delivered Resident #15's meal tray and placed it on the overbed table. NA #1 moved the overbed table around the bed, picked up a wedge pillow and placed it on the top of the bed, moved a chair around the bed, applied a clothing protector to Resident #15, put a straw in the tea using her bare hands, removed a glove from her pocket and placed it on her right hand, and assisted Resident #15 with her meal. NA #1 failed to perform hand hygiene after touching objects in Resident #5's room and assisting the resident with her meal. Observations in Resident #29's room on 4/30/18 beginning at 8:03 AM, revealed CNA #3 touched the bed control, touched the overbed table, donned gloves, and handled Resident #29's biscuit. CNA #3 did not perform hand hygiene prior to donning the gloves and touching Resident #29's biscuit. Observations in Resident #50's room on 4/30/19 at 8:05 AM, revealed CNA #4 donned gloves and assisted Resident #50 with her dentures. CNA #4 continued to set up the breakfast tray wearing the same gloves. CNA #4 did not remove her gloves and perform hand hygiene after touching the dentures and before setting up Resident #50's meal tray. Observations in Resident #37's room on 4/30/19 at 4:50 PM, revealed CNA #2 delivered Resident #37's meal tray. Resident #37 stated, I'm wet . CNA #2 applied gloves and performed pericare. CNA #2 removed her gloves, set up the meal tray, placed a spoon in the bowl, opened the straw, and placed it in the drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 5:48 PM, revealed NA #2 delivered Resident #5's dinner tray an placed it on the overbed table. NA #2 repositioned Resident #5 in bed, removed a pillow from Resident #5's roommate's chair and placed it on the roommate's bed, pulled the chair from the roommate's bedside to Resident #5's bedside, sat in the chair, raised the head of bed using the remote, unwrapped Resident #5's silverware, applied a clothing protector to Resident #5, and assisted Resident #5 with her meal. NA #2 failed to perform hand hygiene after touching objects in Resident #5's room and before assisting the resident with her meal. Interview with CNA #2 on 4/30/19 at 5:36 PM, in the 200 Hall Nurses' Station, CNA #2 was asked what she should have done after performing pericare and before setting up the meal tray. CNA #2 stated, .wash my hands .just forgot . Interview with the Director of Nursing (DON) on 5/1/19 at 9:36 AM, in the DON office, the DON was asked if it was appropriate to perform perineal care, then set up a meal tray without performing hand hygiene. The DON stated, No . Interview with the (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked when she expected staff to perform hand hygiene during dining. The DON stated, Before and after, and if they contaminate themselves, touch part of their body, adjust the patient, or touch another item . The DON was asked if she expected them to perform hand hygiene before and after glove use. The DON stated, Yes, before and after. Interview with the DON on 5/1/19 at 11:28 AM, in the Day Room, the DON was asked if it was appropriate for staff to touch residents' food with their bare hands. The DON stated, No. The DON was asked it it was appropriate for staff to touch inanimate objects in the resident's room with gloves and wear those same gloves to handle the residents' food and tray items. The DON stated, No.",2020-09-01
808,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,880,D,0,1,MD3811,"**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 practices to prevent the potential spread of infection were followed when 1 of 25 (Certified Nursing Assistant (CNA) #5) staff members failed to cover a bedside commode while transporting it through the hall and when 2 of 3 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses failed to change gloves and perform hand hygiene before administering eye drops, failed to rinse and dry a used nebulizer before placing it in a storage bag, and failed to obtain a new piston syringe to administer gastrostomy medications to a resident. The findings include: 1. The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . The facility's .RESPIRATORY SERVICES PROGRAM policy dated 10/99 documented, Cautions .Nebulizer can become contaminated resulting in infection .INFECTION CONTROL .The nebulizer should be allowed to air dry . 2. Observations in Resident #78's room on 4/29/19 at 12:14 PM, revealed CNA #5 had a glove on her right hand only and took a bedside commode with urine in it out into the hall and emptied it in the Soiled Linen Room. CNA #5 did not cover the commode prior to transporting it through the hall to the Soiled Linen Room. Interview with the Director of Nursing (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked how staff should empty bedside commodes. The DON stated, They should wear gloves, take them out of the room to the hopper room. They should have a lid or a cover. The DON was asked if it was appropriate for a CNA to take an uncovered commode containing urine out into the hall. The DON stated, It should have been covered. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #80's room on 4/30/19 beginning at 9:30 AM, revealed RN #1 donned gloves, listened to Resident #80's breath sounds, and checked her oxygen level. RN #1 then placed medication in the breathing treatment nebulizer, attached it to the mask, placed the nebulizer mask on Resident #80, and turned on the breathing treatment machine. RN #1 then administered 1 drop of eye medication to both of Resident #80's eyes. RN #1 did not remove her gloves and perform hand hygiene between preparing the breathing treatment and administering the eye drops. Interview with the DON on 5/1/19 at 11:32 AM, in the Day Room, the DON was asked if it was appropriate to touch the patient and other items in the room while wearing gloves and continue to wear those same gloves to administer eye drops to a resident. The DON stated, No. 4. Observations in Resident #80's room on 4/30/19 at 9:50 AM, revealed RN #1 removed the breathing treatment mask and reservoir from Resident #80 and handed it to LPN #1. LPN #1 placed the used mask and nebulizer in the nebulizer storage bag. LPN #1 did not rinse the used nebulizer and allow it to air dry prior to placing it in the storage bag. Interview with the DON on 5/1/19 at 11:34 AM, in the Day Room, the DON was asked what staff should do after a breathing treatment was completed. The DON stated, .Wash the medicine reservoir after removing it from the mask, let it dry .then place it in the bag . Interview with LPN #1 on 5/1/19 at 11:58 AM, in the 300 Hall, LPN #1 was asked if the nebulizer should have been rinsed and air dried before it was placed in the storage bag. LPN #1 confirmed the nebulizer should have been rinsed and allowed to air dry before it was placed in the storage bag. 5. Observations in Resident #80's room on 4/30/19 at 9:58 AM, revealed RN #1 used a 60 ml (milliliter) piston syringe dated 4/29/19 to administer medications through Resident #80's gastrostomy tube. Interview with RN #1 on 4/30/19 at 10:00 AM, in Resident #80's room, RN #1 looked at the date on the piston syringe and stated, Oh, today's the 30th .it should have been changed . Interview with the DON on 5/1/19 at 11:42 AM, in the Day Room, the DON was asked how often piston syringes for gastrostomy tube medication administration should be changed. The DON stated, Daily .there should have been a new one with the current date for the nurse when she came to the room for med (medication) pass.",2020-09-01
809,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2017-06-02,441,D,0,1,I3EX11,"Based on policy review, observation, and interview 1 of 5 (Licensed Practical Nurses (LPN) #1) nurses observed during medication administration and 1 of 16 (Nurse Aide #1) staff members observed during dining failed to perform hand hygiene to prevent the spread of infection. The findings included: 1. Review of the facility's MEDICATION ADMINISTRATION PER FEEDING TUBE policy documented .1. Knock on patient's door .4. Wash hands and DON gloves 5. Check tube placement .7. Administer medications . Observations at the 100 hall nurses station on 5/30/17 at 11:54 AM, revealed LPN #1 prepared Resident #74's medication, donned gloves, walked to Resident's 74's room, knocked on the door, stopped the tube feeding pump, turned on the faucet with her gloved hand, obtained a cup of water, and turned the water off with her gloved hand. LPN #1 then disconnected the feeding, checked placement by aspiration and auscultation, flushed the tube with water, administered the medication through the tube, flushed the tube with water, reconnected the feeding, discarded her trash, rinsed the syringe used to administer the medication, and placed the syringe in a bag. LPN #1 failed to remove her soiled gloves and perform hand hygiene prior to administering medication to Resident #74. Interview with the Director of Nursing (DON) on 5/31/17 at 10:11 AM, in the DON office, the DON was asked if it was acceptable to put on gloves at the nurses station, touch items in the room, obtain water from a faucet, turn off the faucet and administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without performing hand hygiene and changing gloves. The DON stated, No. 2. Review of the facility's INFECTION CONTROL MANUAL, HANDWASHING policy documented, .wash hands before and after contact with each patient . Observations during dinning on 5/30/17 at 12:19 PM, revealed Nurse Aide #1 washed her hands, touched the remote control to the bed, set up the meal tray, touched the chair, then began feeding the resident without performing hand hygiene. Interview with Certified Nursing Assistant (CNA) #1 and Nurses Aid #1 on 5/30/17 2:39 PM, on the 200 hall CNA #1, and Nurses Aid #1 were asked if it was appropriate to touch the remote control on the bed, move the bedside table, touch a chair and set up the meal tray and not wash their hands before assisting a resident with their meal. CNA #1 stated .we are to wash our hands or use hand sanitizer after touching anything . Interview with the Assistant Director of Nursing (ADON) on 6/1/17 at 8:11 AM, in the day room, the ADON was asked if it was appropriate to touch the remote control on the bed, move the bedside table, and touch the chair without performing hand hygiene, before assisting a resident with a meal. The ADON stated .she should have washed her hands . Interview with Registered Nurse (RN) #1 on 6/01/17 at 10:52 AM, in the conference room, RN #1 was asked if it was appropriate for the nurses aid to touch the remote control, move the bedside table and touch the chair and assist a resident without performing hand hygiene. RN #1 stated, .No, they are taught to wash their hands .",2020-09-01
810,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2017-06-02,514,D,0,1,I3EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for 1 of 14 (Resident #51) sampled residents of the 32 residents included in the stage 2 review. The findings included: 1. Review of the facility's D[NAME]UMENTATION GUIDELINES policy documented .Nurses Notes/Progress Notes are used to record the patient's status and track changes in condition .b) Pertinent nursing observations c) Nursing interventions .2) Progress notes also document: a) Any occurences which are not consistant with the routine care of the patient, b) Nursing interventions to those occurences . Review of the facility's POLICIES AND PR[NAME]EDURES REGARDING CHANGE IN PATIENTS STATUS policy documented .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's family/legal representative . 2. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #51 expired at the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated [DATE] at 11:00 PM, revealed Resident #51 was alert and oriented, receiving oxygen at liters per minute, and had no shortness of breath or pain. The Discharge Summary dated [DATE] documented , .Staff was tending to roommate (roommate) then proceeded to check on Pt (patient) found him w/ (with) (symbol for no) BP (blood pressure), (symbol for no) P (pulse), (symbol for no) Resp (Respirations) . Resident #51 was discharged to the funeral home at 2:20 AM. The facility was unable to provide documentation that the charge nurse, physician or family was notified. Interview with the Director of Nursing (DON) on [DATE] at 2:43 PM, in the DON office, the DON was asked if there was a nurse's note that documented the events between [DATE] at 11:00 PM and the discharge to the funeral home on [DATE] at 2:20 AM. The DON stated, .but we were unable to find it in the chart .",2020-09-01
811,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,689,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the For Your Guidance form, observation, and interview, the facility failed to keep the environment free of accident hazards as evidenced by the presence of mouth wash and aerosol cans in 2 of 54 (room [ROOM NUMBER], and 113) resident rooms. The findings included: Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any items in aerosol cans . Observations in room [ROOM NUMBER] on 6/8/18 at 7:06 AM, 10:13 AM and 4:05 PM, revealed a can of aerosol hair spray sitting on the bedside chest. Observations in room [ROOM NUMBER] on 6/18/18 at 7:14 AM, 10:50 AM, and 4:10 PM, revealed a can of aerosol hair spray sitting on the bedside table. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable to have aerosol cans of hairspray at the bedside. The DON stated, No.",2020-09-01
812,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,692,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nutritional supplements for 1 of 5 (Resident #28) sampled residents reviewed for nutrition. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nutrition Narrative Note dated 6/15/18 documented, She (Resident #28) has lost 7.5 # (pounds) in the past month (6% (percent)) .Will continue to provide regular diet with strawberry mighty shakes to provide extra calories and protein . The Care Plan dated 4/26/18 and revised on 6/15/18 documented, .is a dependent diner .with significant weight .loss .APPROACHES .Regular diet provided .with strawberry mightyshake (mighty shake) at mealtime . Observations in Resident #28s room on 6/19/18 at 2:20 PM and 6/20/18 at 8:23 AM, revealed Resident #28 did not receive a strawberry mighty shake at meal time. Interview with the Dietary Manager (DM) on 6/20/18 at 9:05 AM, in the Dietary office, the DM was asked about Resident #28s diet. The DM stated, .strawberry mighty shakes with meals . The DM was asked when does Resident #28 get her mighty shakes. The DM stated, We will provide on her meal trays. The DM was asked how the staff knew to send the mighty shakes on her tray. The DM stated, It should be on the tray card. The DM was shown the tray card and she confirmed the mighty shakes were not on the tray card. The DM stated, It should be on there. The DM was asked if she expected the mighty shakes to be on the meal trays. The DM stated, Um'huh and shook her head yes.",2020-09-01
813,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,761,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely as evidenced by unattended medications in 3 of 54 (room [ROOM NUMBER], 114, and 301) resident rooms. The findings included: Review of the MEDICATION STORAGE IN THE FACILITY policy documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications . Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any medicated items .Over the counter medications . Observations in room [ROOM NUMBER] on 6/18/18 at 7:06 AM,10:13 AM, and 4:05 PM, revealed a [MEDICATION NAME] inhaler in the room. Observations in room [ROOM NUMBER] on 6/18/18 at 7:17 AM, 10:25 AM, and 12:53 AM, revealed 1 bottle of aspirin, 1 box of medicated pain patches, and a jar of [MEDICATION NAME] skin protectant in the room. Observations In room [ROOM NUMBER] on 6/18/18 at 4:18 PM, revealed a tube of Icy Hot (pain relieving cream) sitting by the sink. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable for a resident to have a [MEDICATION NAME] inhaler at the bedside. The DON stated, No . The DON was asked if it was acceptable to have a bottle of aspirin stored in the resident's room. The DON stated, No. The DON as asked if it was acceptable to have a box of medicated pain patches stored at the bedside. The DON stated, No. The DON was asked if it was acceptable to have [MEDICATION NAME] skin protectant stored at the bedside. The DON stated, No. Interview with the DON on 6/18/18 at 4:19 PM, in room [ROOM NUMBER], the DON confirmed a tube of Icy Hot was sitting by the sink.",2020-09-01
814,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,656,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to develop a plan of care to address moods for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact, and exhibited little interest, feeling down/depressed, tired, and change of appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed the BIMS score of 14/15; and exhibited feeling down/depressed for 2-6 days of the review period. Medical record review of the care plan with completion date of 11/30/17 and revised in 1/19/18 revealed feeling down/depressed and tired were not addressed. Interview with the Registered Nurse (RN) #1/ MDS Coordinator on 2/21/18 at 8:45 AM in the conference room confirmed the care plan with completion date of 11/30/17 failed to address the resident was down/depressed and tired. Further interview confirmed the care plan with the completion date of 1/19/18 failed to address feeling down/depressed.",2020-09-01
815,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,657,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to timely revise a plan of care to address manipulative behaviors for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs .are reviewed and/or revised . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited little interest, feeling down/depressed, tired, change appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; BIMS score of 14/15; exhibited feeling down/depressed for 2-6 days of the review period; and exhibited no [MEDICAL CONDITIONS], or behaviors. Medical record review of facility documentation dated 1/31/18 revealed Resident #6 informed Certified Nurse Aide (CNA) #3 of CNA #1 got in bed with Resident #6 on 1/30/18. Further facility documentation review revealed the resident had made a false accusation. Medical record review of the care plan dated 2/12/18 revealed on a problem was initiated addressing the resident .exhibiting behavior symptoms as making false accusations toward staff while providing care and being manipulative toward staff when providing care . The approaches dated 2/12/18 included .Acknowledge resident feelings & (and) try to negotiate an agreement to stay until all concerned parties can be brought together to satisfactorily strategize the resident's needs; Document behaviors. Attempt to identify pattern to target interventions; Staff will enter (resident's) room with two people to provide care due to making false allegations . The approach dated 2/16/18 revealed .Will be refer to psych (psychiatric) for evaluation . Interview with the Registered Nurse (RN) #1/MDS Coordinator on 2/21/18 at 8:45 AM in the conference room revealed the comprehensive care plan and the Certified Nurse Aide (CNA) Bedside Care Plans, addressing resident care and needs, were updated with any new concerns or interventions. Further interview confirmed the facility failed to timely revise the care plan after the false allegation and manipulation of staff was reported on 1/31/18. Interview with the Social Worker (SW) on 2/21/18 at 9:32 AM in the conference room confirmed the SW was responsible to address behaviors on the MDS and the care plan. Further interview confirmed the facility failed to timely revise the care plan after the resident's false allegation and manipulation of staff was reported on 1/31/18. Interview with the Administrator on 2/21/18 at 10:52 AM in the conference room confirmed the facility failed to revise the care plan timely after the event was reported on 1/31/18.",2020-09-01
816,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,686,D,0,1,KVF711,"**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 follow physician's orders related to wound care dressing change for 1 resident (#133) of 15 residents receiving wound care. The findings include: Facility policy review, Dressings, Dry/Clean, dated (MONTH) 2013, revealed .Verify that there is a physician's order for this procedure .Apply the ordered dressing .Label with date and initials to top of dressing . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report dated (MONTH) 2019 through (MONTH) 2019 revealed .clean with NS (normal saline) pat dry, pack wound with calcium alginate AG (silver), cover with bordered foam dressing every day shift and as needed if dressing becomes dislodged or soiled . Observation of the wound care performed by Licensed Practical Nurse (LPN, wound care nurse) #4 for Resident #133, with the Wound Director present, on 3/25/19 at 12:32 PM in Resident #133's room, revealed the resident's wound dressing was dated 3/22/19. Interview with LPN #4 on 3/25/19 at 12:32 PM in Resident #133's room confirmed the wound dressing was dated 3/22/19. Interview with the Wound Director on 3/25/19 at 12:48 PM in the 100 Hallway confirmed Resident #133's wound dressing was dated 3/22/19 and the dressing was ordered to be changed daily. Interview with the Director of Nursing on 3/26/19 at 3:17 PM in her office confirmed she expected the nurses to follow physician's orders exactly how they are written.",2020-09-01
817,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,695,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review, observation and interview, the facility failed to provide necessary respiratory care for residents 2 (#24 and #482 ) of 37 residents receiving respiratory services. The findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #24's physician order [REDACTED].Change nebulizer mask and tubing weekly; date and place in dated plastic bag (Sun. night). Place in dated bag when not in use . Medical record review of the Care Plan dated 2/25/19 revealed .has [MEDICAL CONDITION] r/t (related to) history of [MEDICAL CONDITION] . Medical record review of the Care Plan dated 3/1/19 to 3/26/19 revealed .at risk for altered breathing pattern r/t (related to) congestion, use of supplemental oxygen, Pneumonia . Observation of Resident #24 in the residents room on 3/24/19 at 9:10 AM and again at 11:35 AM revealed the Nebulizer and tubing lying on the bedside stand unbagged and undated. Medical record review revealed Resident #482 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #482 in the residents room on 3/24/19 at 9:45 AM and again at 3:17 PM revealed the Bilevel Positive Airway Pressure mask ([MEDICAL CONDITION]) and tubing drapped over the bedside stand unbagged and undated. Further observation on 3/24/19 at 12:39 PM revealed nasal cannual oxygen tubing on the floor. Interview with Licensed Practical Nurse #9 on 3/24/19 at 3:18 PM in Resident #24's room and Resident #482's room confirmed . that the nebulizer and tubing needed to be in the bag when not in use .",2020-09-01
818,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,726,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review, observation, and interview, the facility failed to ensure nursing staff have the knowledge and competencies, and skill sets for staging pressure ulcer 1 resident (#100) of 15 residents with staging pressure ulcers. The findings include: Review of the Medical record revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Wound Admission assessment dated [DATE] revealed . unstageable to bilateral heels, golf size black/purple areas bilaterally . Medical record review of the of the Weekly Wound Report dated 1/16/19 revealed .suspected deep tissue injury of bilateral heels . Interview with the Regional Wound Care Consultant on 3/26/19 at 4:30 PMin the Director of Nursing office revealed, the wound assessment dated [DATE] was . inaccurate . Continued interview revealed the wound was a . deep tissue injury as described on 1/16/19 . Interview with the Regional Wound Care Consultant and Director of Nursing (DON) on 3/26/19 at 5:30 PM and 6:30 PM, respectfully, in the DON's office confirmed wound competencies on the staging of pressue ulcers with the nursing staff have not been done.",2020-09-01
819,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,756,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the pharmacist failed to make recommendations for a stop date related to a prn (as needed) anti-psychotic medication for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications ate limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders, trade name [MEDICATION NAME]) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's Order Summary Report dated (MONTH) through (MONTH) 2019 revealed no [MEDICAL CONDITION] drug side effect or behavior monitoring in place for the [MEDICATION NAME]. Medical record review of Resident #121's Medication Administration Record [REDACTED]. Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have a 14 day stop date for [MEDICATION NAME]. Continued interview confirmed the pharmacist evaluates each resident's medications monthly and sends the facility a report of the recommendations. Telephone interview with the Pharmacist on 3/26/19 at 4:07 PM and at 5:25 PM confirmed when a resident has a prn antipsychotic/[MEDICAL CONDITION] drug ordered, it is limited to 14 days and the resident has to be reevaluated by the physician to extend the prn 14 day stop date. Continued interview when asked about pharmacy recommendations for Resident #121 she stated if she (Resident #121) had an order for [REDACTED].#121).",2020-09-01
820,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,757,D,0,1,KVF711,"**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 [MEDICAL CONDITION]/antipsychotic drug side effect or behavior monitoring in place for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications are limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] (trade name [MEDICATION NAME]) [MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's Order Summary Report dated (MONTH) thru (MONTH) 2019 revealed there were no [MEDICAL CONDITION] drug or behavior monitoring in place for [MEDICATION NAME]. Medical record review of Resident #121's Medication Administration Record [REDACTED]. Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Telephone interview with Resident #121's Hospice Physician on 3/26/19 at 12:18 PM confirmed side effect monitoring is a team effort between hospice and the facility and side effects should be monitored and documented. Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have any [MEDICAL CONDITION] side effect or behavior monitoring in place.",2020-09-01
821,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,758,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to provide an adequate [DIAGNOSES REDACTED].#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings, including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications are limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders, trade name [MEDICATION NAME]) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Telephone interview with Resident #121's Hospice Physician on 3/26/19 at 12:18 PM confirmed she was aware of the 14 day stop date for [MEDICAL CONDITION] medications and stated with hospice patients we have prn (as needed) [MEDICATION NAME] for [MEDICAL CONDITION] and terminal agitation. Continued interview when asked if agitation was a correct [DIAGNOSES REDACTED]. Continued interview confirmed she stated side effect monitoring is a team effort between hospice and the facility and side effects should be monitored and documented. Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have a 14 day stop date for the prn [MEDICATION NAME]. Continued interview when asked to look at the resident's [DIAGNOSES REDACTED]. Continued interview confirmed the resident has to be reevaluated by the physician to extend the 14 day stop date for a prn anti-psychotic. Continued interview when asked if Resident #121 was re-evaluated by the physician to extend the prn medication stop date she stated no.",2020-09-01
822,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,761,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to refrigerate and properly store medications on 4 of 12 medication carts. The findings include: Review of facility policy, Administering Medications, dated 2001, revised (MONTH) 2012, revealed .When opening a multi-dose container, the date opened shall be recorded on the container .Staff shall follow established facility infection control procedures for the administration of medications . Review of facility policy, Storage of Medications, dated 2001, revised (MONTH) 2007, revealed .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .The nursing staff shall be responsible for maintaining medication storage AND preparation areas .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications .Medications requiring refrigeration must be stored in a refrigerator . Observation of the 300B medication cart on [DATE] at 5:20 PM in the hallway with Licensed Practical Nurse (LPN) #1revealed the following: a multiple dose bottle of Optimum Lacto Bacillus (a medication used for the restoration of normal intestinal bacteria after antibiotic use) opened and not dated; a multiple dose bottle of [MEDICATION NAME] (a medication used for pain or fever) 325 milligram (mg) 100 count bottle opened and not dated; a multiple dose bottle of [MEDICATION NAME] 500 mg 100 count bottle opened and not dated; a multiple dose bottle of Aspirin (a medication given for pain, fever, or as an anticoagulant) 325 mg 100 count bottle opened and not dated; a multiple dose bottle of [MEDICATION NAME] (a liquid medication used for upset stomach) 355 milliliters (ml) opened not dated; 1 tube of Preparation H (an ointment used for relief of Hemorrhoids) opened, not dated and not labeled with a resident identifier. Continued observation revealed 1 intravenous (IV) catheter adapter dated ,[DATE], expired. Observation of the 100A medication cart on [DATE] at 5:45 PM in the hallway with LPN #5 revealed the following: a multiple dose bottle of [MEDICATION NAME] (a medication used to thin mucous secretions) 400 mg opened and not dated; a multiple dose bottle of [MEDICATION NAME] solution (a liquid medication used for constipation) 10 milligram per milliliter (mg/ml) opened and not dated; a multiple dose bottle of Dakins solution (a liquid medication used to irrigate wounds) opened and not dated; a multiple dose bottle of Valporic acid (a medication used for treating [MEDICAL CONDITION]) opened and not dated; and a [MEDICATION NAME] suppository (a stimulant/laxative) not labeled with a resident identifier, and not stored in the original container. Observation of the 200B medication cart on [DATE] at 2:30 PM in the 200B nurses station with LPN #7 revealed the following: a multiple dose bottle of [MEDICATION NAME] 5 mg tablets 150 count opened with expiration date [DATE]; 4 [MEDICATION NAME] (used for inhalation treatment for [REDACTED]. Observation of the 400B medication cart on [DATE] at 3:00 PM in the hallway with LPN #8 revealed the following: a FirVanq suspension (an oral form of the antibiotic [MEDICATION NAME] used to treat infections) 25 mg/ml 150 ml bottle unrefrigerated and at room temperature; 2 individually packaged [MEDICATION NAME] (a medication for [MEDICAL CONDITION]) capsules loose in drawer unlabeled; 10 [MEDICATION NAME] not in their original protective foil package, and undated; [MEDICATION NAME] powder (a topical used for fungal rashes) undated and unlabeled; a tube of Vit A&D ointment, a tube of Skin Protective ointment, a tube of Skin Repair ointment, and a tube of [MEDICATION NAME] ointment (all 4 topicals used for prevention and treatment of [REDACTED]. Interview with the Director of Nursing on [DATE] at 6:16 PM in her office confirmed .medications should be stored appropriately on all med carts .",2020-09-01
823,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,880,D,0,1,KVF711,"**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 maintain ice storage container and scoop in a sanitary manner. The findings include: Review of the facility's policy, Ice Machines and Ice Storage chest, revised (MONTH) 2012, revealed .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Ice making machines, ice storage chests/containers, and ice can all become contaminated by: Unsanitary manipulation by employees, residents, and visitors; Improper storage or handle of ice .To prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: Limit access to ice machines or ice storage chests/containers to employees only; Do not handle ice directly by hand; Keep the ice scoop/bin in a covered container when not in use . Medical record review revealed Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #146's quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Observation on 3/25/19 at 8:30 AM on the 200 hall revealed an unattended ice storage container cart with an empty clear plastic bag sitting on the top of the cart. Continued observation revealed no ice scoop placed in the plastic bag or on top of the cart. Observations on 3/25/19 at 8:55 AM and 10:18 AM on the 200 hall revealed Resident #146 walked up to the unattended ice cart and took the top off of her water pitcher and placed it on top of the cart. Continued observation revealed the resident opened the lid of the ice chest, reached into the chest with her bare hands obtaining the ice scoop from inside the chest. Continued observation revealed the resident filled her cup with ice, replaced the ice scoop back into the ice chest and closed the lid. Interview with Resident #146 on 3/25/19 at 8:55 AM on the 200 hall by the ice storage cart revealed when asked if she got ice from that container she stated I always get my own ice with the scooper, I never touch the ice just the scooper and then I put the scooper back in the container. Interview with the Director of Nursing on 3/25/19 at 10:43 AM on the 200 hall by the ice storage cart confirmed the ice scoop was to be stored in a bag and not in the ice chest. Continued interview when asked the process of passing ice confirmed the CNA's (Certified Nurse Aides) use the cart to pass ice, they are supposed to pass the ice and remove the cart from the hall; Residents should not be getting ice out of it.",2020-09-01
824,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,224,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview the facility failed to prevent misappropriation of resident medication for 1 of 14 (Resident #58) residents reviewed with controlled substance records. The findings included: 1. The facility's Administering Medications policy documented, .Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5 mg (milligrams)/325 mg tab (1) po (by mouth) q (every) 6 hrs (hours) PRN (as needed) Pain . Review of the CONTROLLED SUBSTANCES record for Resident #58's [MEDICATION NAME] administration tracking revealed the following: 1/27/17 9:15 PM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, 1 Borrowed for (Resident #213) 1/28/17 6:00 AM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, 1 Borrowed for (Resident #213) 1/28/17 7:00 AM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, Borrowed for (Resident #213) 1/30/17 12:15 PM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, Borrowed for (Resident #194) Review of Resident #58's Medication Administration Record [REDACTED]. 3. Medical record review revealed Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]/acet. ([MEDICATION NAME]) 5-325 mg tab - take (1) po q 6 hours PRN pain . Review of Resident #213's (MONTH) (YEAR) MARs revealed Resident #213 received [MEDICATION NAME] on 1/27/17 at 9:15 PM, on 1/28/17 at 6:00 AM, and on 1/28/17 at 7:00 AM. 4. Medical record review revealed Resident #194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A PHYSICIAN'S TELEPHONE ORDERS dated 1/30/17 documented, .[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 (mg) take 1 tablet BID (twice a day) PRN pain . Review of Resident #194's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Administrator on 6/3/17 at 7:57 PM, in the conference room, the Administrator was asked if it was appropriate for nursing staff to borrow a resident's medication in order to given it to another resident. The Administrator stated, No.",2020-09-01
826,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,241,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to treat a resident with dignity and respect when 1 of 3 (Licensed Practical Nurse (LPN) #7) nurses failed to introduce self or explain all procedures to a resident prior to performing care for that resident. The findings included: The facility's Quality of Life - Dignity policy documented, .Residents shall be treated with dignity and respect at all times .Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 6/1/17 at 8:18 AM, revealed LPN #7 checked placement of Resident #25's Percutaneous Endoscopic Gastrostomy (PEG) tube, administered medications through the PEG tube, administered eye drops to both Resident #30's eyes, administered insulin by subcutaneous injection into Resident #25's left arm, turned Resident #25 on her side in the bed and applied a medicated patch to Resident #25's back. LPN #7 did not introduce self or explain the procedures prior to beginning the treatments, and did not talk to the resident during the care. Interview with LPN #7 on 6/02/17 at 5:06 PM, at the Station 1 Nurses' Station, LPN #7 was asked if it was acceptable to provide care to a nonverbal resident or any other resident without informing the resident what was being done. LPN #7 stated, Absolutely not. LPN #7 was asked if a resident should be informed before they are given an injection or turned. LPN #7 stated, Yes. Interview with the interim Director of Nursing (DON) on 6/3/17 at 12:29 PM in the conference room, the interim DON was asked if it was acceptable to provide care, give injections, administer eye drops, or turn a resident without explaining what is being done to the resident. The interim DON stated, No, it doesn't matter whether they are cognitively impaired, aphasic or whatever, you introduce yourself to the patient and explain what you are doing.",2020-09-01
827,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,242,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to honor a resident's choice for meal intake for 1 of 1 (Resident #273) residents reviewed for choices. The findings included: The facility's Resident Rights policy documented, .Freedom of choice to make their own, independent decisions (including refusal of treatment) .Quality care and treatment .have care provided in accordance with their care plan .Participate in care planning . Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and received insulin injections. Observation on 5/30/17 at 4:44 PM, 5/31/17 at 9:18 AM, and 5/31/17 at 10:03 AM, revealed a sign posted on Resident #273's door which documented, No sugar please. Interview with Resident #273's family member on 6/1/17 at 5:35 PM, in Resident #273's room, Resident #273's family member was asked if the facility had tried to change Resident #273's diet according to her wishes for a diabetic diet and supplements. Resident #273's family member stated, I have talked to the Dietitian, and she told me they don't have a special diabetic menu .she could leave things off of her tray .she was getting desserts .she got sweet tea, and we requested unsweet tea .they stated they only have one kind of tea and it's sweet tea .so I asked for milk .the Ensure is a problem too because they are not sugar free . Resident #273's family member was asked whether the facility provided choices for Resident #273. Resident #273's family member stated, No . Interview with Certified Nursing Assistant (CNA) #2 on 6/2/17 at 11:52 AM, on the Station 4A hall, CNA #2 was asked whether she gave Resident #273 her meal tray today. CNA #2 stated, Yes. CNA #2 was asked what type of tea Resident #273 had with her lunch tray. CNA #2 stated, Sweet tea. CNA #2 was asked if she was aware Resident #273 was a diabetic. CNA #2 stated, No .I know there is a sign on the door that says no sugar. Interview with Registered Dietitian (RD) #1 on 6/2/17 at 3:38 PM, in the conference room, RD #1 was asked what type of tea is served on the halls. RD #1 stated, It's sweet tea. RD #1 was asked what interventions were in place for the diabetic residents. RD #1 stated, I tell them we don't have a therapeutic diet . Interview with the interim Director of Nursing (DON) on 6/3/17 at 3:48 PM, in the conference room, the interim DON was asked if a diabetic resident could get a diabetic diet if requested. The interim DON stated, .we should provide what their preferences are. The interim DON was asked if it was acceptable not to honor the resident and family request for no sugar. The interim DON stated, .we should honor their preferences.",2020-09-01
831,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,329,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to document behaviors and side effects for [MEDICAL CONDITION] medications for 1 of 5 (Resident #205) residents reviewed for unnecessary medications of the 41 sampled residents in the Stage 2 review. The findings included: Medical Record review revealed Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment, Resident # 206 received antipsychotic, antianxiety, and antidepressant medications 7 out of 7 days and had wandering behaviors daily. Review of the quarterly MDS dated [DATE] revealed a BIMS of 3, indicating severe cognitive impairment, received antipsychotic and antidepressant medications 7 out of 7 days and antianxiety medications 3 out of 7 days, and did not have behaviors. Review of the care plan revealed, Focus .Alteration in mood state and behaviors r/t (related to) [MEDICAL CONDITION] and anxiety .experiencing agitation, wandering with exit seeking behaviors, delusional ideations, low frustration tolerance .Interventions Administer [MEDICAL CONDITION] meds (medications) per order and observe for .Anxiety, [MEDICAL CONDITION], nausea, diarrhea, involuntary muscle movements, muscle stiffness, [MEDICAL CONDITION], constipation, eps (extrapyramidal symptoms) . Review of the physician's orders [REDACTED].#205 had an order for [REDACTED]. Review of the (YEAR) PSYCHOACTIVE MEDICATION MONTHLY FLOW RECORD revealed the following: a. Psychoactive Medication monitoring: Behavioral Symptoms: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. Side Effects: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. b. Antidepressant Medication monitoring: Side Effects: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. Interview with the interim Director of Nursing (DON) on 6/1/17 at 5:20 PM, in the conference room, the interim DON was asked to explain the blanks on the the PSYCHOACTIVE MEDICATION MONTHLY FLOW RECORD. The interim DON stated, .if I see this, it looks like it was not done. The interim DON was asked whether Resident #205 should be monitored daily. The interim DON stated, .typically that's what is recommended, for psych (psychoactive), [MEDICAL CONDITION], antianxiety, the antidepressants, they are monitoring for side effects. Interview with Licensed Practical Nurse (LPN) #9 on 6/1/17 at 5:35 PM, on the 200 hall, LPN #9 was asked how frequently behavior monitoring should be done. LPN #9 stated, Normally it should be done every shift. Interview with LPN #9 on 6/2/17 at 5:09 PM, on the 200 A hall, LPN #9 was asked what monitoring was done for each high risk medication administered to residents. LPN #9 stated, Monitor every shift and chart any changes that occur . LPN #9 was asked what monitoring tools or systems are used. The LPN #9 stated, The behavior monitoring form.",2020-09-01
833,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,362,D,0,1,35VZ11,"Based on policy review, observation, and interview, the facility failed to ensure adequate dining staff was available to provide timely delivery of meals on 1 of 4 (2B) halls. The findings included: 1. The facility's Timely Meal Service policy documented, .Food will be delivered promptly to assure proper temperatures and high quality food .Meals will be placed in the cart in sequence to achieve the most effective service .Meals are distributed promptly with supervision as needed by nursing staff . 2. Observations on the 2B hall on 6/2/17 at 11:50 AM, revealed the non-insulated lunch meal tray cart arrived on the hall containing meals for 22 residents. Certified Nursing Assistant (CNA) #8 began delivering meal trays to residents. The meal cart was left on the hall while CNA #8 delivered trays and served the residents. 3. Observations on the 2B hall on 6/2/17 at 12:55 PM, revealed CNA #8 removed a tray from the same meal cart that had been sitting in the hall for 1 hour and 5 minutes, delivered it to Resident #130 in her room, and began assisting the resident to eat. 4. Interview with the Administrator on 6/2/17 at 6:23 PM, in the conference room, the Administrator was asked whether it was acceptable for the meal cart to sit out in the hall for over an hour before all the meals were served to the residents. The Administrator stated, .we have 84 feeders in the building .that's why we utilize the feeding assistant program .",2020-09-01
835,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,385,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to obtain a physician's order for transfer to a geriatric psychiatric (geri-psych) facility for 1 of 2 (Resident #206) residents reviewed for behaviors in the stage 2 review. The findings included: The Transfer or Discharge Documentation policy documented, .Should the resident be transferred or discharged .the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician . Medical record review revealed Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 3/9/17 at 5:55 PM, revealed that Resident #206 was transported by Emergency Medical Services to (named geri-psych facility). Review of the physician's orders revealed no order for transfer to a geri-psych facility. Interview with the Administrator on 6/3/17 at 7:56 PM, in the conference room, the Administrator was asked if there should be a physician's order when a resident is discharged or transferred to another facility. The Administrator stated, Yes. The Administrator was asked if she had found an order to transfer Resident #206 to the (named geri-psych facility). The administrator stated, No.",2020-09-01
836,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,431,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were not stored past their expiration date in 3 of 17 storage areas (1 A/B treatment cart, 4B treatment cart, and wound treatment cart). The findings included: 1. The facility's Administering Medications policy documented .The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container . Observations in the 100 hall A/B treatment cart on [DATE] at 11:47 AM, revealed the following medications were stored past their expiration date: a. 3 ounce bottle antifungal powder with an expiration date of [DATE] b. 2 16 ounce bottles Hydrogen Peroxide with an expiration date of [DATE] c. 1 32 ounce Hydrogen Peroxide bottle with an expiration date of [DATE] d. 1 8 ounce Povidone Iodine bottle with an expiration date of ,[DATE] Observations in the 400 A hall medication cart on [DATE] at 3:12 PM, revealed Germ-X 15 ounce bottle with an expiration date of ,[DATE]. Observations in the 400 B hall medication cart on [DATE] at 3:43 PM, revealed an 8 ounce bottle of Hydrogen Peroxide with an expiration date of ,[DATE]. Interview with LPN #8 on [DATE] at 3:10 PM, on the 100 hall at the A/B treatment cart, LPN #8 was asked whether it was acceptable to have medications that are expired in the treatment cart. LPN #8 stated, Oh no, ma'am, no ma'am. Interview with Registered Nurse (RN) #3 on [DATE] at 3:20 PM, on the 400 A hall, RN #3 was asked whether it was acceptable to have medications and disinfectants that are expired in the treatment cart. RN #3 stated, No, I would say expired Germ-X is not acceptable. Interview with LPN #1 on [DATE] at 3:43 PM, on the 400 B hall, LPN #1 was asked whether it was acceptable to have medications that are expired in the treatment cart. LPN #1 stated, No. Interview with the Administrator on [DATE] at 8:01 PM, in the conference room, the Administrator was asked if it was acceptable to have expired Povidone Iodine, Hydrogen peroxide, Miconazole Powder, and Germ-X on the medication or treatment carts. The Administrator stated, No, it is not acceptable.",2020-09-01
837,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,441,D,0,1,35VZ11,"**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 practices to prevent the potential spread of infection were followed as evidenced by failure of the facility to maintain contact isolation precautions for 1 of 2 (Resident #36) sampled residents in contact isolation, by failure of 2 of 2 (Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #6) staff members to handle linens appropriately after performing patient care, by failure of 2 of 2 (Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #1) to perform proper hand hygiene, and by failure of 1 of 2 (RN #1) staff to properly dispose of biohazardous materials during wound care. The findings included: 1. The facility's .Isolation - Categories of Transmission-Based Precautions documented, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions .In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Examples of infections requiring Contact Precautions include .Infections with multi-drug resistant organisms .Place the individual in a private room if possible .In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room .While caring for a resident, change gloves after having contact with infective material .Remove gloves before leaving the room and perform hand hygiene .After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room .Wear a disposable gown upon entering the Contact Precautions room .After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces .For individuals with .excretions, secretions, or drainage that is difficult to contain, maintain precautions . The facility's Handwashing/Hand Hygiene policy documented, .Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . The facility's Laundry and Bedding, Soiled policy documented, .Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminates items . 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented, .Brief Interview for Mental Status (BIMS) .BIMS Summary Score .12 (moderate cognitive impairment) .Urinary .Frequently incontinent .7 or more episodes of urinary incontinence . The quarterly MDS dated [DATE] documented, .Urinary .Occasionally incontinent . The care plan dated 4/21/17 documented, .DIURETIC THERAPY .5/29 (2017) .ESBL (Extended Spectrum Beta-Lactamase) .Contact Isolation .FREQ (frequent) BLADDER INCONT (incontinence) R/T (related to) URGE, REQUIRES ASSIST WITH .TOILETING .Interventions/Tasks .INCONT CARE Q (every) 2HRS (2 hours) AND PRN (as needed) .TOILETING .EXT (extensive) ASSIST FOR TRANSFERS, PERICARE (perineal care), CLOTHING . The nurse's note dated 5/30/17 documented, .incontinent of B (bowel) (and) B (bladder) (with) Pericare (perineal) care provided . The Activity of Daily Living (ADL) documentation sheets documented Resident #36 had urinary incontinence episodes daily from 5/1/17-5/31/17. The urinalysis with culture and sensitivity with a collection date of 5/25/17 documented, .ESCHERICHIA COLI ES RESISTANCE DUE TO (ESBL) EXTENDED SPECTRUM B-LACTAMASE .Started on .Contact Iso (isolation) . The telephone physician's orders [REDACTED].Contact .Isolation x (times) 7 days .ESBL . Observations in the front lobby of the facility on 5/31/17 at 2:40 PM, and 6/1/17 at 11:34 AM, revealed Resident #36 sitting on a folded incontinence pad in a wheelchair with other residents present in the lobby. Interview with Certified Nursing Assistant (CNA) #7 on 6/3/17 at 10:20 PM, at the Station 1 Nurses' Desk, CNA #7 was asked whether Resident #36 was continent of urine. CNA #7 stated, Not during the night. CNA #7 was asked whether Resident #36 was normally wet when she goes in to do incontinence checks on her. CNA #7 stated, Yes. CNA #7 confirmed she performs incontinence care for Resident #36 due to urinary incontinence. Interview with Registered Nurse (RN) #2 at the Station 1 Nurses' Desk on 6/3/17 at 10:30 PM, RN #2 was asked whether res #36 was continent of bowel and bladder. RN #2 looked in the medical record and stated, .She is incontinent of B&B (bowel and bladder) .staff always performs pericare. Interview with the Director of Nursing (DON) on 6/3/17 at 11:39 PM, in the conference room, the DON was asked whether it was appropriate for a resident that is incontinent of urine and that has a [DIAGNOSES REDACTED]. The DON stated, Not if incontinent . 3. Observations on the Station 1 Hall on 6/1/17 at 11:24 AM, revealed CNA #6 walking down the hall holding numerous linens, including a gown that had a wet brown substance on it. CNA #6 was carried the items and held them against the door of the dirty linen room, as she attempted to open the door. Observations in Resident #273 room on 6/1/17 at 4:49 PM, 5:04 PM, and 5:11 PM, revealed RN #1 washed her hands, and turned off the faucet with the same wet paper towel she dried her hands with. Observations in Resident #273's room on 6/1/17 at 5:10 PM and 5:17 PM, revealed CNA #1 washed her hands and turned off the faucet with the same wet paper towel she dried her hands with. Observations in Resident #273's room on 6/1/17 at 5:20 PM, revealed RN #1 removed the barrier pad used during dressing change of Resident #273's bilateral heels. RN #1 picked up the barrier pad with a paper towel, and carried the soiled pad down the hall for disposal. Observations on the treatment cart outside of Residents #273's room on 6/1/17 at 5:25 PM, revealed RN #1 placed the biohazard bag in the regular trash can on the treatment cart. Interview with CNA #6 on 6/1/17 at 11:26 AM, in the soiled linen room, CNA #6 was asked how soiled linen should be carried to the soiled linen room. CNA #6 stated, It should be carried in a plastic bag . CNA #6 was asked whether the linen she just took into the soiled linen room had been carried out into the hallway in a bag. CNA #6 stated, No ma'am, I did not. Interview with RN #1 on 6/1/17 at 5:29 PM, at the treatment cart, RN #1 was asked what is standard procedure for turning off the faucet after hand hygiene. The RN #1 stated, You would use a paper towel to turn it off .a clean paper towel. RN #1 was asked if it was acceptable to turn off the faucet with the same wet paper towel you dried your hands with. RN #1 stated, I don't know. RN #1 was asked if was acceptable to carry dirty linen down the hallway without placing it in a plastic bag. The RN #1 stated, If it was soiled, I would put it in a bag . RN #1 was asked what is policy for removing linen from a resident's room. RN #1 stated, We would put it in a plastic bag and carry it to the linen barrel. Interview with the Director of Nursing (DON) on 6/1/17 5:48 PM, in the front office, the DON was asked if it was acceptable to turn off the faucet with the same wet paper towel after hand washing. The DON stated, No .now you have contaminated that sink and your hands. The DON was asked if it was acceptable to place a biohazard bag in the treatment cart trash can in a regular trash bag. The DON stated, No it is not. The DON was asked if it was acceptable to carry used linen from a resident room in the hallway without placing it in plastic bag. The DON stated, No .they should not be carrying it down the hall without a plastic bag. Interview with the Administrator on 6/2/17 at 11:24 AM, at the Station 4 Nursing Station, the Administrator was if it was appropriate for soiled linens to be carried through the hallway to the soiled linen area without being contained. The Administrator stated, No, it should be placed in a bag before it leaves the room.",2020-09-01
843,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-06-20,761,D,0,1,QBCZ11,"**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 properly store a medication in a locked compartment for 1 of 159 residents (Resident #59) reviewed. Findings include: Review of facility policy Storage of Medications, revised (MONTH) 2007, revealed .Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .the nursing staff shall be responsible for maintaining medication storage . Medical record review revealed the facility admitted Resident #59 on 11/12/16 then readmitted the resident on 6/12/18 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) for Resident #59 dated 5/4/18 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 7 indicating the resident was severely cognitively impaired. Medical record review of the physician's orders [REDACTED].#59 revealed .[MEDICATION NAME]-[MEDICATION NAME] Solution ([MEDICATION NAME][MEDICATION NAME]) 0.5-2.5 (3) milligram (mg) 3 milliliter (ml) 3 ml inhale orally every 6 hours related to [MEDICAL CONDITION] (acute) Exacerbation . Observation on 6/18/18 at 10:40 AM in Resident #59's room revealed an unopened single dose vial of [MEDICATION NAME]/[MEDICATION NAME] 0.5mg/2.5ml laying in a chair beside a nebulizer machine. Interview with Licensed Practical Nurse (LPN) #1 on 6/18/18 at 10:44 AM in Resident #59's room confirmed nurses perform residents' nebulizer treatments. Further interview with LPN #1 confirmed the facility failed to properly store the medication. LPN #1 stated No medicine should ever be laying there.",2020-09-01
844,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-06-20,880,D,0,1,QBCZ11,"**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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 159 residents, (Resident #59, Resident #349, and Resident #350), reviewed related to labeling and storage of oxygen tubing and masks, and 1 of 8 residents (Resident #128) reviewed related to labeling and storage of irrigation syringes. Findings include: Review of facility policy Oxygen Administration, not dated, revealed .Oxygen tubing will be changed as ordered and PRN, and tubing will be dated to indicate last date of tubing change . Medical record review revealed the facility admitted Resident #59 on 11/12/16 then readmitted the resident on 6/12/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for Resident #59 dated 5/4/18 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 7 indicating the resident was severely cognitively impaired. Further review of the MDS section O revealed Resident #59 was receiving oxygen (02) therapy. Review of the physician's orders [REDACTED].change 02 tubing and humidifier every night shift every Sun (Sunday) .02 at 2L/min (2 liters per minute) via nasal cannula. every shift related to [MEDICAL CONDITION] with (Acute) Exacerbation . Observations of Resident #59 on 6/18/18 at 10:40 AM and at 4:25 PM and on 6/19/18 at 7:48 AM revealed oxygen via nasal cannula (n/c) at 2 liters per minute (l/m), the oxygen tubing was not dated. Further observations revealed a nebulizer mask and tubing lying in a chair not dated or stored in a bag. Continued observation revealed a portable oxygen tank with oxygen tubing attached to the tank. The oxygen tubing was not dated or stored in a bag. Record review revealed Resident #349 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS for Resident #349 dated 6/13/18 revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Further review of the MDS section O revealed the resident had a [MEDICAL CONDITION] and was receiving oxygen therapy. Medical record review of the physician's orders [REDACTED].oxygen [MEDICAL CONDITION] to keep sats (Saturations) above 90% . Observations of Resident #349 on 6/18/18 at 10:28 AM and on 6/19/18 at 7:31 AM revealed oxygen in use via [MEDICAL CONDITION] mask with the oxygen tubing not dated. Continued observation revealed a portable oxygen tank was sitting at the end of the bed with a [MEDICAL CONDITION] mask attached and the mask was not stored in a bag and was not dated. Further observation on 6/18/18 at 4:19 PM revealed oxygen in use via [MEDICAL CONDITION] per portable oxygen tank and the oxygen tubing was not dated. Medical record review revealed Resident #350 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].change and date 02 tubing and humidification every night shift every Sun (Sunday) .02 (Oxygen) @ (at) 3L/M (3 liters per minute) via NC (Nasal Cannula) every shift . Observations of Resident #350 on 6/18/18 at 11:10 AM and at 4:28 PM and on 6/19/18 at 7:44 AM revealed the resident sitting up in a recliner with 02 via n/c at 3 l/m and the oxygen tubing was not dated. Further observation revealed an oxygen mask and tubing hanging on an IV (Intravenous) pole not in use and not dated or stored in a bag. Review of facility policy Enteral Feeding Tubes and Care, not dated revealed .Store bulb syringe in its dated wrapper and discard after 24 hours . Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS for Resident #128 dated 6/8/18 section K revealed the resident had a feeding tube. Review of the physician's orders [REDACTED].two times a day (BID) 120ml (milliters) water flush BID when TF (Tube Feeding) is started and stopped .every shift may mix all allowable medications and administer via [DEVICE] (Gastrostomy Tube) . Observation in Resident #128's room on 6/18/18 at 11:15 AM and at 4:24 PM and on 6/19/18 at 7:41 AM revealed an irrigation syringe lying on a bedside table opened and not dated. Further observation revealed the syringe had clear liquid and debris in the end of the syringe. Interview with the Director of Nursing (DON) on 6/19/18 at 8:14 AM on the 400 hall confirmed all oxygen tubing and masks should be dated and bagged if not in use. The DON stated the nurses are responsible for changing oxygen tubing and tubing should be changed weekly. Continued interview with the DON confirmed all irrigation syringes when opened should be dated and stored in a bag after use and the facility failed to properly date and store masks, tubing, and syringes.",2020-09-01
846,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-09-25,626,D,1,0,GEY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to document its inability to meet the resident's needs for 1 (#5) of 7 residents reviewed for Admission/Transfer/Discharge criteria. The findings include: Review of facility policy, Transfer Agreement, revised 3/2017, revealed .Our facility has a transfer agreement in place with a designated hospital should our residents need care that is beyond the scope of our available care and services .The agreement ensures that residents are transferred from the facility to the hospital and admitted in a timely manner in an emergency situation by another practitioner .The agreement specifies restrictions with respect to the types of services available and types of residents or health conditions that will not be accepted by the hospital or the facility .Inquiries related to the transfer agreement should be referred to the Administrator . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers and bathing; required extensive assistance of 2 people with bed mobility, dressing, toileting, and grooming; and was frequently incontinent of bowel and bladder. Medical record review revealed multiple episodes of refusing care; yelling and cursing at staff; family trying to use a mechanical lift to transfer him without staff being present; and family bringing in medications and other materials not associated with his care. Medical record review revealed Resident #5 was sent to the hospital with unresponsiveness and the facility refused to allow him to return due to inability to meet his needs. Medical record review revealed no documentation the Ombudsman was notified of the Residents discharge. Medical record review revealed no documentation in the record of the specific needs which could not be met at the facility; attempts made by the facility to meet those needs, or the services another facility could provide. This failure of documentation was confirmed by the Administrator on 9/25/19 at 4:40 PM in the conference room.",2020-09-01
847,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,609,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to report an investigation for 1 resident ( #24) of 24 residents reviewed to the state agency. The findings include: Review of the facility policy revised 7/2017 Abuse Investigation and Reporting revealed .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his /her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the facility investigation dated 10/18/18 revealed there not an investigation completed. Interview with the Administrator on 11/21/18 at 3:52 PM in his office revealed Resident #24 reported an allegation of abuse. Further interview when asked why the allegation was not reported to the state agency the Administrator responded .Resident #24 told us in conversation that nurse was rough with her and then she retracted her statement . Further interview confirmed .we proceeded as an informal investigation .",2020-09-01
848,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,610,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to do a completed investigation for 1 resident (#24) of 24 residents reviewed for abuse. The finidings include: Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Interview with the Director Of Nursing on 11/27/18 at 12:22 PM in the conference room revealed completed an informal investigation. Further interview confirmed she did not complete a formal interview because the resident retracted her statement.",2020-09-01
849,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,690,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview revealed the facility failed to have a [DIAGNOSES REDACTED].#24) of 6 with Foley catheters. The findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the physician orders [REDACTED].Foley-insert for diuresis . Observation on 11/21/18 and 11/26/18 Resident #24 had a Foley Catheter in place. Interview Resident #24 on 11/21/18 at 3:01 PM in her room revealed she had requested for a Foley Catheter. Interview with Nurse Practitioner (NP) on 11/21/18 at 1:24 PM in the conference room revealed Resident #24 never had urine retention, and could void. Further interview confirmed it was for her comfort that is the reason for the catheter. She does not have it for [MEDICAL CONDITION] nor does she need it. It was never intended for long term use, only for a short amount of time.",2020-09-01
850,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,580,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician services of the failure to administer an as needed diuretic as ordered after a weight gain as ordered; the failure to obtain daily weights as ordered; the failure to obtain laboratory tests as ordered; and the failure to administer a daily diuretic as ordered for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligrams (mg) 1 tab by po (by mouth) once every day as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling ([MEDICAL CONDITION]), or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN (every day as needed) r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight, in pounds, documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Medical record review revealed no laboratory test results for 10/10/17 as ordered for the CBC, BMP and BNP. Review of the Admission Nursing Note dated 11/2/17 revealed Resident #1 had 1+ [MEDICAL CONDITION] on bilateral lower extremities. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician. Interview with the Nurse Practitioner (NP) #1 on 12/18/17 at 2:30 PM in the conference room confirmed the NP had not been notified the daily weights had not been obtained, the PRN [MEDICATION NAME] had not been administered after the weight gain on 11/4/17, the 10/10/17 laboratory tests were not obtained and the [MEDICATION NAME] 20 mg daily order had not been transcribed or administered.",2020-09-01
851,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,607,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, video review, facility investigation review, and interview, the facility staff failed to report an allegation of abuse to the facility administration per policy for 1 resident (#2) of 9 residents reviewed. The findings included: Review of the undated facility policy, Abuse, Neglect and Exploitation of Residents, revealed .Responsibilities .All personnel .if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay .will .report any signs of suspected abuse, neglect and exploitation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged as a 911 at 5:24 PM to the emergency room following the event. Review of the video dated 9/19/17 from 4:07:45 PM to 4:07:55 PM revealed Certified Nurse Aide (CNA) #1 leaning against the hallway wall when Resident #2 aggressively and with fisted hands attempting to strike the second employee. Further review of the 2 views of the video revealed these were the only 2 employees in the area at the time of the event. Review of the facility investigation included CNA #1's interview on 10/24/17 revealed the CNA was asked why she did not report the event when it occurred the CNA .stated due to all the staff being there that the event was reported . Interview with the Administrator on 12/12/17 at 9:30 AM in the conference room revealed the event which occurred on 9/19/17 was reported on 10/24/17 when the agency CNA #1 involved informed the shift supervisor. The shift supervisor then called the Administrator to report the allegation and the investigation was started. Further interview confirmed the facility staff failed to report the allegation to the facility administration immediately per policy.",2020-09-01
852,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,684,D,1,0,RPNN11,"**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].#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po (by mouth) once every day (Q D) as needed ( PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BMP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician.",2020-09-01
854,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,842,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po once every day (Q D) as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. 2. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] a [MEDICATION NAME][MEDICATION NAME]) 0.5 mg-2.5mg/3 milliliters (ml) 3 ml inhalation 4 times daily (QID). Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in days. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID (4 times a day) 3. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 D was administered on 11/13/17 and 11/14/17. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Of the 50 opportunities for administration 16 treatments were not administered with no supporting documentation for 14 administrations. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Further interview revealed the LPN was not aware she was to document the reason for not administering a medication on the back of the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR and the facility failed to do so. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident. The facility failed to maintain a complete and accurate medical record.",2020-09-01
857,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,550,D,0,1,B3ST11,"Based on policy review, observation, and interview, the facility failed to maintain the resident's dignity and respect when 3 of 13 (Registered Nurse (RN) #1, Director of Nursing (DON), and Certified Nursing Assistant (CNA) #1 and #9) staff members failed to knock on the resident's door prior to entering the resident's room and referred to residents as feeders during dining observations. The findings include: 1. The facility's undated Right to Dignity policy documented, .The elder will always be addressed by the name preferred by the elder Staff will knock on the door and wait for permission to enter when entering the elder's personal space . 2. Observations outside Resident #19's room on 4/15/19 beginning at 12:29 PM, revealed RN #1 entered the resident's room to deliver a meal tray without knocking. RN #1 returned to the meal cart and took a meal tray to Resident #43, and did not knock prior to entering the resident's room. RN #1 then walked out of Resident #43's room, re-entered the room to awaken Resident #15, and found Resident #15 wet. RN #1 left the room to find housekeeping, re-entered Resident #15's room to clean and dry the resident without knocking. Observations outside Resident #13's room on 4/15/19 at 12:54 PM, revealed the DON entered Resident #13's room with a meal tray without knocking. Observations outside Resident #39's room on 4/16/19 at 7:50 AM, revealed CNA #1 entered the resident's room to deliver a meal tray without knocking. 3. Observations in the Dining Room on 4/17/19 at 7:30 AM, revealed CNA #9 stated, She is a feeder . referring to Resident #26. There was another resident sitting at the table with Resident #26. Interview with the DON on 4/17/19 at 6:40 PM, in the Administrator Office, the DON was asked if staff should call residents feeders. The DON stated, No, ma'am.",2020-09-01
858,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,565,D,0,1,B3ST11,"Based on the Resident Council Meeting Minutes, observation, and interview, the facility failed to respond to the Resident Councils concerns for 6 of 6 months (November and (MONTH) (YEAR), and January, February, March, and (MONTH) 2019). The findings include: 1. The Resident Council Minutes dated 11/16/18 documented, .Ice still isn't being passed . 2. The Resident Council Minutes dated 12/5/18 documented, .Bathroom floors being wet .Water pitches (pitchers) / ice not being passed . 3. The Resident Council Minutes dated 1/10/19 documented, .Beds are not being made . 4. The Resident Council Minutes dated 2/6/19 documented, .staff being in hallway, talking to other staff discussing other resident's information .Playing on their phones not responding to resident's requesting assistance . 5. The Resident Council Minutes dated 3/6/19 documented, .staff discussing other resident's information has not improved .playing on their phones in the hallways not responding to resident's request hasn't improved .water pitchers not being passed .call lights not being answered . 6. Resident Council Meetings dated 4/3/19 documented, .water pitchers being passed has not improved .call lights being answered has not improved . 7. The Resident Council was held on 4/16/19 at 1:47 PM, in the Dining Room, Resident #39 and residents attending the meeting unanimously agreed that the shower water ran around the toilet area and they could not go to the bathroom without soaking their feet, staff members discussed other resident's information while rounding continued, and water pitchers and ice were not passed. 8. Interview with the Activities Director on 4/16/19 at 5:34 PM, in the Administrator Office, the Activities Director was asked what was the process for reporting grievances from the Resident Council. The Activities Director stated, .I give the complaints to the appropriate department heads . The Activities Director was asked how does she know when issues are resolved. The Activities Director stated, .they tell me they have done an audit or an inservice with the appropriate staff . The Activities Director was asked if the resident's complaints were being resolved. The Activities Director stated, .well .they don't seem to be . 9. Interview with the Administrator on 4/17/19 at 7:30 AM, in the Administrator Office, the Administrator was asked to provide the method by documentation that Resident Council complaints or grievances had been resolved. The documentation on how resident's complaints were resolved was never provided.",2020-09-01
859,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,569,D,0,1,B3ST11,"Based on review of the residents' trust accounts and interview, the facility failed to ensure residents receiving Medicaid funding did not have trust fund balances that exceed the Supplemental Security Income (SSI) limit for 2 of 55 (Resident #11 & #36) resident trust accounts reviewed for the quarter ending 3/29/19. The findings include: 1. The quarterly statements dated 3/29/19 were reviewed, and revealed the following: a. Resident #11's balance was $4514.97 b. Resident #36's balance was $4416.98 2. Interview with the Business Office Manager on 4/16/19 at 2:31 PM, in the Administrator Office, the Business Office Manager was asked should the accounts be over $2200.00. The Business Office Manager stated, No .",2020-09-01
860,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,582,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Notice of Medicare Non-Coverage, and interview, the facility failed to provide an appropriate notice to the resident and/or legal representative in writing when skilled services were terminated for 1 of 4 (Resident #103) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. The Notice of Medicare Non-Coverage documented, .Services Will End: 4/1/19 .Signature of Patient Representative .Date .4/10/19 . 3. An e-mail from the Business Office Manager to Resident #103's legal representative with a Notice of Medicare Non-Coverage attachment was dated 4/1/19. 4. Interview with Resident #103's legal representative on 4/15/19 at 11:11 AM, in Resident #103's room, Resident #103's legal representative was asked if she would be the person the facility would notify if there were changes in Resident #103's status. Resident #103's legal representative stated, .I have issues with the facility's communication .I got the notice my mother would be private pay the same day that services were completed and when I called the (Named Business Office Manager), she told me my mother would be private pay . Interview with the Business Office Manager on 4/17/19 at 9:35 AM, in the Business Office, the Business Office Manager was asked when was the Notice of Medicare Non-Coverage (NOMNC) sent to Resident #103's responsible party to advise of skilled services ending. The Business Office Manager stated, .April 1, 2019 . The Business Office Manager was asked when did Resident #103's skilled services end and when shoukld the NOMNC be given to the responsible party. The Business Office Manager stated, .I e-mailed the NOMNC form to (Named Responsible Party) on 4/1/19 per her request .the NOMNC is supposed to be given to the responsible party 24 hours prior to skilled services being discontinued .",2020-09-01
861,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,636,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 3 of 39 (Resident #10, 101, and 200) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) pages 2-20 through 2-22 documented, .The Admission assessment .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z500B) must be no later than day 14 .The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) .The ARD (Assessment Reference Date) (Item A2300) must be sent within 366 days after the ARD of the previous OBRA (Omnibus Budget Reconciliation Act) comprehensive assessment (ARD of previous assessment +366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly .The MDS completion date (Item A0500B) must be no later than 14 days after the ARD . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD date of 3/25/19 revealed Item Z0500B was not complete. The annual MDS assessment should have been completed by 4/8/19 but had never been completed. 4. Medical record review revealed Resident #101 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD date 3/14/19 revealed Item Z0500B was incomplete. The admission MDS should have been completed on 3/27/19 but had never been completed. 6. Medical record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD date of 3/26/19 revealed Item Z0500B was incomplete. The admission MDS should have been completed by 4/9/19 but had never been completed. 7. Interview with the Director of Clinical Reimbursement on 4/16/19 at 9:17 AM, in the Administrator Office, the Director of Clinical Reimbursement confirmed the MDS assessments for Resident #10, 101, and 200 were not completed timely.",2020-09-01
862,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,637,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a significant change assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 1 of 39 (Resident #45) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-24 documented, .The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than . 2. Medical record review revealed Resident #45 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date 3/24/19 revealed Item Z0500B was incomplete. The significant change MDS should have been completed by 4/7/19 but had never been completed. Interview with the Director of Clinical Reimbursement on 4/16/19 at 9:17 AM, in the Administrator Office, the Director of Clinical Reimbursement confirmed the MDS assessments for Resident #45 was not completed timely.",2020-09-01
863,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,638,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 4 of 39 (Resident #4, #6, #23, and #102) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date 3/19/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 4/2/19 but had never been completed. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 3/13/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/27/19 but had never been completed. 4. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 3/7/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/21/19 but had never been completed. 5. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 3/4/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/18/19 but had never been completed. 6. The Director of Clinical Reimbursement on 4/16/19 at 9:18 AM, in the Administrator Office, confirmed the MDS assessments for Resident #4, 6, 23, and 102 were not completed timely.",2020-09-01
864,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,657,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident rights, policy review, medical record review, and interview, the facility failed to ensure each resident and/or resident's legal representative was involved in developing the care plan and making decisions about his or her care for 1 of 18 (Resident #103) sampled residents reviewed. The findings include: 1. The facility's Resident's Rights Under Federal Law documented, .The Resident has a right to participate in planning his or her care and treatment and treatment . The facility's Care Planning - Interdisciplinary Team policy dated (MONTH) 1, 2010 documented, .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . 2. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. Interview with Resident #103's legal representative on 4/15/19 at 11:07 AM, in Resident #103's room, Resident #103's legal representative was asked if she had been invited to a care plan meeting or had staff reviewed Resident #103's care plan with her. The legal representative stated, No, I have not received an invitation .it seems the facility is between social workers. Interview with the Assistant Director of Nursing (ADON) on 4/17/19 at 1:37 PM, in the Administrator Office, the ADON was asked what was the process for the initial care plan meeting. The ADON stated, .The normal process is to create and print the resident's care plan within the first 24 hours and then the Social Worker reviews the care plan with the resident's responsible party and has the responsible party sign the care plan . The ADON confirmed Resident #103's care plan had not been signed and could not verify the care plan had been reviewed with Resident #103's daughter.",2020-09-01
866,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,688,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure interventions were in place to prevent further decrease in range of motion for 1 of 1 (Resident #102) sampled residents reviewed for range of motion. The findings include: 1. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] documented Resident #102 is rarely understood, had severe cognitive impairment, required extensive to total assistance with activities of daily living, and had functional limitations in range of motion with impairment in all extremities. The care plan dated 9/7/18 and revised 2/28/19 documented, .OT (Occupational Therapy) to eval (evaluate) and treat for orthotic management of bilateral hand contractures . The Restorative Referral dated 4/11/19 documented, .Comments: *Splint to (L) (left) leg x (for) 4 hours (R) (right) leg for 4 hours .Splinting to (R) hand x 4 hours .Splinting w (with) / carrot (L) hand x 4 hours . 2. Observations in Resident #102's room on 4/15/19 at 9:55 AM,12:06 PM, and 3:18 PM, and 4/16/19 at 5:05 PM, and 6:25 PM, revealed Resident #102 was observed in his bed. A carrot (type of splint) and hand splint was observed on the window sill at the foot of his bed. 3. Interview with Physical Therapy Assistant (PTA) on 4/16/19 at 1:07 PM, in the Therapy Room, the PTA was asked why Resident #102 was on therapy's case load. The PTA stated, .he (Resident #102) was seen for therapy for positioning and splinting .we discharged him from our case load on 4/11/19 . Interview with Certified Nursing Assistant (CNA) #2 on 4/16/19 at 5:13 PM, in room [ROOM NUMBER] (a vacant room), CNA #2 was asked whose responsibility it was to apply Resident #102's splints. CNA #2 stated, .mine .I'm still learning how to put the splints on his legs . CNA #2 was asked to explain why Resident #102's splints had not been applied the last two days. CNA #2 stated, .it's my responsibility to apply the splints and if I don't know how, it's my responsibility to ask for assistance and additional training . Interview with the Director of Nursing (DON) on 4/16/19 at 6:25 PM, at the Main Nurses' Desk, the DON was asked if she would expect the nursing staff to apply splints. The DON stated, Yes.",2020-09-01
868,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,693,D,0,1,B3ST11,"**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 care and services to promote safe and effective nourishment by enteral tube feedings for 1 of 1 ( Resident #29) sampled residents reviewed for tube feedings. The findings include: The facility's undated Enteral Tube Feeding via Continuous Pump policy documented, .Documentation .The person performing this procedure should record the following information in the resident's medical record .Gastric residual volume .Report other information in accordance with facility policy and professional standards of practice . Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 Physician order [REDACTED].@ (at) 65 CC/HR (cubic centimeters per hour) x (for) 22 HRS/DAY (hours per day) VIA TUBE . Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. Observations in Resident #29's room on 4/15/19 at 11:51 AM, and 4/16/19 at 4:04 PM, revealed the enteral feeding tubing was not dated. Interview with the Director of Nursing (DON) on 4/17/19 at 8:57 AM, in the Administrator Office, the DON was asked where tubing changes would be documented. The DON stated, I would on the TAR .I do not see it on here . Interview with the DON on 4/17/19 at 9:19 AM, in the Administrator Office, the DON was asked how often the enteral tube feeding residuals should be documented. The DON stated, Every shift. Interview with the DON on 4/17/19 at 9:47 AM, in the Administrator Office, the DON was asked if the residuals were documented every shift. The DON stated, No.",2020-09-01
873,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,225,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure a complete, thorough, and timely investigation was conducted for resident to resident altercations for 2 of 4 (Resident #3 and 6) sampled residents. The findings included: 1. The facility's Abuse, Neglect, Misappropriation of Resident Funds policy documented .Reporting of abuse, Neglect, or Misappropriation/Procedure 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the administrator or Director of Nursing (DON) .The names of any witnesses to the incident .7. Upon receiving information concerning a report of abuse, neglect, misappropriation, the Administrator or designee will investigate, obtain statements, and ensure the residents are safe and receive quality care . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an incident documented, On 2/19 (2/19/17 at 10:40 AM) resident (Resident #3) was witnessed by other residents in the dining room running into the chair of resident (Resident #6). During this event resident (Resident #6)attempted to hit resident (Resident #3) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON (Director of Nursing) and Administrator . Review of the POS [REDACTED].Immediate Post-Incident Action: CNAs (Certified Nursing Assistant) informed to keep the 2 separated for today and to be [MEDICAL CONDITION] .Immediate actions Taken: Assessed for injuries, separated the 2 involved to different rooms, vital signs taken, asked him about what happened . 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].Narrative of incident: When in dining room, elder was hit in the face by another elder. No employees were present. 3 other elders were able to report the incident. Immediate Post-Incident action: Try to keep elders involved separated in the dining area. Assessed for injuries and separate to different rooms . Interview with the Assistant Director of Nursing (ADON) on 5/23/17 at 2:38 PM, in the DON's office, the ADON was asked to describe the incident between Resident #3 and Resident #6. The ADON stated, I do not know who the other 3 residents were that witnessed it and the nurse that filed the report is no longer here . Interview with the Administrator on 5/23/17 at 2:43 PM, in the DON's office, the Administrator was asked to describe the incident between Resident #38 and Resident #6, the investigation, and who were the 3 other residents that witnessed the incident. The Administrator stated, .I don't have a witness statement in there (looking through the investigation report) .I sure thought the statements were in there .I have had some renovation done to my office and they moved my desk around and may have slipped out of the file .I first put down that she was hit in the mouth but actually that was a growth on her lip area. She did not get hit in the mouth .the second altercation is when he hit her and I kept him in my office until the paramedics could come and get him out .when we have someone that has an altercation like that we separate them .make sure everyone is ok .get statements .monitor them .redirect them . Interview with the Administrator on 5/23/17 at 3:58 PM, in the DON's office, the Administrator was asked if he had statements from the witnesses. The Administrator stated, No .that is my fault for not following up on it .(the witnesses) they would have been able to tell you what happened right then but the next day they couldn't have told you . The facility failed to complete a thorough investigation of the incident that occurred between Resident #38 and 6.",2020-09-01
874,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,280,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan to reflect current status for 3 of 20 (Resident #38, 6, and 42) sampled residents reviewed of the 33 residents included in stage 2. The findings included: 1. Review of the facility's CARE PLANS - COMPREHENSIVE policy documented, .Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly and upon change of condition . 2. Review of an incident documented, .On 2/19 (2/19/17 at 10:40 AM) resident #3289 (Resident #38) was witnessed by other residents in dining room running into chair of resident (Resident #6). During this event resident (Resident #38) attempted to hit resident (Resident #6) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON(Director of Nursing) and Administrator . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's care plan dated 5/12/16 revealed no documentation of the altercation with Resident #6 that occurred on 2/19/17. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's care plan for behaviors dated 2/3/15 revealed no documentation of the altercation with Resident #3 that occurred on 2/19/17. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 4:53 PM, in the DON's office, the IDON was asked if she would expect the care plans to be updated to reflect the altercation that occurred on 5/9/17. The IDON stated, Yes. The IDON was asked if the care plans for Resident #38 and 6 had been updated to reflect the altercation that occurred on 2/19/17. The IDON stated, No. 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #42 had a fall on 5/19/17 at 9:51 AM while attempting to cross the threshold of the front entrance foyer when his wheelchair tipped over backwards resulting in a skin tear to his left forearm and the intervention included weights to be placed on the front of Resident #42's wheelchair and the furniture in front entrance foyer rearranged. Review of Resident #42's care plan dated 11/8/16 revealed no documentation of Resident #42's risk for falls or the fall that occurred on 5/19/17. Interview with the Minimum Data Set (MDS) Coordinator on 5/24/17 at 1:39 PM, in the Social Service's Office, the MDS Coordinator was asked if a resident who had a [DIAGNOSES REDACTED]. The MDS Coordinator stated, Yes. The MDS Coordinator was then asked if Resident #42 had a fall on 5/19/17 should the care plan have been updated to reflect that fall and the interventions that were put into place. The MDS Coordinator stated, Yes, it should .",2020-09-01
875,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,309,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow the physician's orders for laboratory tests for 1 of 20 (Resident #71) sampled residents reviewed of the 33 included in stage 2. The findings included: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone orders dated 10/7/16 documented, CBC (complete blood count), with Diff (differential), CMP (Comprehensive Metabolic Panel) D-Dimer, PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) (on) 10/11/16 . There were no laboratory results dated [DATE] for the CBC with Diff, CMP, D-Dimer, PT/INR found in the medical record. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 10:10 AM, in the hallway outside her office, the IDON stated she could not locate the laboratory results.",2020-09-01
878,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,680,D,0,1,C62611,"Based on review of the Activity Director's job description, Activity Director's personnel file, and interview, the facility failed to ensure the position of 1 of 8 (Activity Director ) staff members was filled by a qualified staff member as evidenced by no documentation the Activity Director completed the required course. The facility had a census of 46 residents. The findings included: The Activity Director's job description documented, .is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current state, and local standards, guidelines and regulations .must be knowledgeable of regulations governing activity services in nursing care facilities . Review of the Activity Director's personnel file revealed a hire date of 10/21/16 as a Certified Nursing Assistant. On 12/27/16 she acquired the position of Activity Director. Interview with the Activity Director on 6/13/18 at 5:55 PM, in the Conference room, the Activity Director confirmed she had taken the position of the Activity Director in (MONTH) (YEAR), and had not completed the required training for the Activity Director position. Interview with the Nursing Consultant on 6/13/18 at 7:55 PM, in the conference room, the Nursing Consultant confirmed the Activity Director had not completed the required training for the Activity Director position.",2020-09-01
879,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,698,D,0,1,C62611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for a resident receiving [MEDICAL TREATMENT] for 1 of 1 (Resident #33) sampled residents receiving [MEDICAL TREATMENT] by failing to accurately assess the resident's access site for [MEDICAL TREATMENT]. The findings included: 1. The facility's Post [MEDICAL TREATMENT] Care policy documented, .The post-[MEDICAL TREATMENT] nursing assessment, includes, but not limited to: Assessment of access site for bleeding Assessment of AV fistula/graft strength or thrill and bruit .Check & Monitor Shunt site appearance and bruit Once during the three 8 hour shifts to observe for any complications .Check Vascular Access Device and Dressing After [MEDICAL TREATMENT] To evaluate and monitor for any changes . 2. Medical record review revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #33 had moderate cognitive deficits, required supervisory assistance with all activities of daily living, and received [MEDICAL TREATMENT]. The care plan dated 2/8/17 documented Resident #33 had interventions for complications related to [MEDICAL TREATMENT] including, .monitor placement of cath (catheter) as needed and notify MD (Medical Doctor)/[MEDICAL TREATMENT] immediately if any changes to site noted .monitor cath site for signs/symptoms of infection and notify MD/[MEDICAL TREATMENT] as needed . The General Nursing Notes did not document assessments of the access site were performed for the dates of: 3/2-4/18, 3/6/18, 3/9/18, 3/12-13/18, 3/15/18, 3/17/18, 3/18-24/18, 3/26-27/18, 4/10/18, 4/12/18, 4/15-20/18, 4/22-25/18, 5/1-3/18, 5/5-8/18, 5/17-20/18, 5/24-28/18, and 5/30-31/18. The [MEDICAL TREATMENT] Center Communication Form completed by the facility prior to the resident going to [MEDICAL TREATMENT] documented a Bruit/Thrill was present for the dates of 4/12/18, 4/14/18, 4/18/18, 4/21/18, 4/26/18, 4/28/18, 5/10/18, 5/12/18, 5/19/18, 5/24/18, 5/26/18, 6/5/18, 6/7/18, and 6/9/18. The Nurse's Note dated 4/27/18, 5/3/18, 5/4/18, 5/7/18, 5/9/18, and 5/11/18 documented resident was positive for a thrill and bruit. The Nurse's Note dated 4/27/18 and 5/11/18 documented Resident #33 had a shunt. Interview with the Director of Nursing (DON) on 6/13/18 at 1:40 PM, in the conference room, the DON was asked what type of [MEDICAL TREATMENT] access Resident #33 had. The DON stated, .a [MEDICAL TREATMENT] port . The DON was asked if a bruit/thrill should be assessed and documented. The DON stated, .Not for a [MEDICAL TREATMENT] port . The facility failed to provide documentation that assessments were completed for Resident #33's access site for [MEDICAL TREATMENT]. The facility also failed to assess the access site accurately by documenting Resident #33 had a shunt rather than a [MEDICAL TREATMENT] port and the staff was documenting a thrill/bruit was present. Interview with Resident #33 on 6/13/18 at 9:30 AM, in the dining room, Resident #33 was asked if the staff ever checked his shunt site. Resident #33 stated, .Naw, no .maybe every now and then . Interview with the DON on 6/13/18 1:45 PM, in the conference room, the DON stated, .the resident has a [MEDICAL TREATMENT] port and the charting is inaccurate . Interview with the Nursing Consultant on 6/13/18 at 4:40 PM, in the conference room, the Consultant was asked what she expected the staff to chart regarding a [MEDICAL TREATMENT] resident. The Consultant stated, .we are lacking in the documentation area and the sites should be assessed every shift .",2020-09-01
881,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,880,D,0,1,C62611,"**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 infection control practices were followed to prevent the spread of infection when 1 of 2 (Certified Nursing Assistant (CNA) #2) staff members did not perform proper hand hygiene during catheter care. The findings included: The facility's Handwashing/Hand Hygiene-Procedure policy documented, .The purpose of this procedure is to provide guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infection .a. Before and after direct contact with residents .d. after removing gloves . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #7's room on 6/12/18 at 1:50 PM, revealed CNA #2 and CNA #3 did not perform hand hygiene before providing catheter care for Resident #7. CNA #2 left the resident's room during care and returned to the room without performing hand hygiene. Interview with CNA #2 on 6/12/18 at 6:05 PM, in the Conference room, CNA #2 was asked what should be done after removing gloves and prior to applying new gloves. CNA #2 stated, Wash my hands . Interview with the Director of Nursing (DON) on 6/13/18 at 2:47 PM, in the Conference room, the DON was asked what should be done before performing catheter care. The DON stated, .wash hands as soon as they go in that door . The DON was asked what should be done after removing gloves and applying new gloves. The DON stated, .wash .",2020-09-01
883,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2019-03-13,561,D,0,1,SJSF11,"Based on policy review, observation, and interview, 1 of 13 (Certified Nursing Assistant (CNA) #1) staff members failed to offer food substitutes to Resident #16, #151, and #251 during dining observations. The findings include: The facility's Frequency of Meals policy documented, .Meals will also comply with resident needs, preferences, requests, and plan of care . Observation in Resident #251's room on 3/11/19 at 11:25 AM revealed CNA #1 served Resident #251 a meal tray. Resident #251 stated, I don't like noodles. CNA #1 failed to offer the resident an alternate selection of food. Observation in Resident #151's room on 3/11/19 at 11:30 AM revealed CNA #1 served Resident #151 a meal tray. Resident #151 stated, .I don't want green beans. CNA #1 failed to offer a food substitution for the green beans. Observation in Resident #16's room on 3/11/19 at 11:35 AM revealed CNA #1 served Resident #16 a meal tray. Resident #16 stated, Where is the milk? CNA failed to provide Resident #16 the milk requested. Interview with the Director of Nursing (DON) on 3/12/19 at 2:50 PM in the Conference Room, the DON was asked if a resident voiced a dislike for a food item, should a substitution be offered. The DON stated, Yes.",2020-09-01
885,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2019-03-13,812,D,0,1,SJSF11,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions when 1 of 13 (Certified Nursing Assistant (CNA) #1) staff members failed to perform hand hygiene during dining observations for Residents ##8, #16, and #251, and the facility failed to properly handle thawed chicken in the kitchen. The facility had a census of 62 residents, with 2 of those residents receiving a meal tray with chicken served from the kitchen. The findings include: 1. The facility's Hand Hygiene policy dated 4/20/18 documented, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table .After handling contaminated objects . Observations in Resident #251's room on 3/11/19 at 11:25 AM revealed CNA #1 moved a wheelchair, placed the overbed table next to Resident #251, locked the wheelchair, replaced the overbed table, and then prepared the meal tray without performing hand hygiene. Observations in Resident #8's room on 3/11/19 at 11:27 AM revealed CNA #1 removed the knee rest from Resident #8's wheelchair, placed the call light next to the resident, then served Resident #8's meal tray without performing hand hygiene. Observations in Resident #16's room on 3/11/19 at 11:35AM revealed CNA #1 touched the hand rail and prepared the meal tray without performing hand hygiene. Observations in Resident #26's room on 3/12/19 at 7:16 AM revealed CNA #1 elevated the head of the bed, touched a cord in the wall, and then prepared the meal tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 3/12/19 at 9:45 AM in the Conference Room, the DON was asked what staff should do during dining when objects in the environment were touched. The DON stated, They should sanitize. 2. The facility's PROPER THAWING TECHNIQUES policy dated (MONTH) 2014 documented, .Foods should be cooked promptly after thawing . 3. Observations in the Kitchen on 3/12/19 at 10:53 AM revealed 5 pieces of thawed chicken breast in the bottom of the sink. The chicken breasts were not completely submerged under cold running water. Interview with Dietary Staff #1 on 3/12/19 at 10:53 AM in the Kitchen, Dietary Staff #1 was if raw chicken breasts should be left in the sink. Dietary Staff #1 stated, No, ma'am .was there when I got here . Interview with the Certified Dietary Manger (CDM) on 3/13/19 at 7:51 AM in the Conference Room, the CDM was asked if raw chicken breasts should be left in the sink. The CDM stated, .was using it for the alternate and she had unthawed it .was running under cold water .I walked away .from that point on I don't know what happened .she forgot it is the only thing I can come up with .should have taken it out . Interview with the Registered Dietician (RD) on 3/13/19 at 10:48 AM in the Training Room, the RD was asked if thawed chicken breasts should be left in the sink. The RD stated, No.",2020-09-01
888,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,761,D,0,1,U8U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and safely in 1 of 5 (Medication Cart #1) medication storage areas and failed to ensure medications were stored securely when 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses left medications unattended. The findings include: 1. The facility's Storage of Medications policy revised (MONTH) 2007 documented, .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medication . The facility's Administering of Medications policy revised (MONTH) 2012 documented, .No medications are kept on top of the cart .The cart must be clearly visible to the personnel administering medications . 2. Observations in Medication Cart #1's drawer on 7/1/19 at 9:54 AM, revealed the following: a. 1 pack of Adult wipes b. 4 bottles of Polyethylenene [MEDICATION NAME] c. 1 bottle of [MEDICATION NAME] Syrup d. 1 bottle of Mucus & Chest Congestion e. 1 bottle of Pro Stat sugar free f. 1 bottle of [MEDICATION NAME] g. 1 bottle of Sore Throat spray h. 1 bottle of Acid Gas Relief tablets i. 1 box of Anti-Diarrheal tablets Interview with LPN #2 on 7/1/19 at 9:57 AM, at Medication Cart #1, LPN #2 was asked should adult wipes be stored in the same compartment with medications on the medication cart. LPN #2 stated, No, ma'am. Observations on 7/1/19 at 4:09 PM, outside of Residents #4's room, revealed LPN #4 placed a vial of [MEDICATION NAME] and a vial of Humalog on top of the medication cart. LPN #4 entered Resident #4's room, closed the door, and left the 2 vials of insulin on top of the medication cart unattended and out of sight. LPN #4 returned to the medication cart and drew up the insulin. LPN #4 returned to Resident #4's room, administered the insulin, and left the vials of insulin on the medication cart unattended and out sight of the nurse. Observations on 7/2/19 at 4:38 PM, outside of Resident #14's room, revealed LPN #4 placed 2 packaged Tylenol capsules on the medication cart and stated the Tylenol were on hold. LPN #4 left the Tylenol in their package on top of her computer key board, out of sight and unattended. LPN #4 entered Resident #14's room, closed the door, and completed her medication administration. Interview with LPN #4 on 7/2/19 at 4:48 PM, outside of Resident #14's room, LPN #4 was asked should medications be on top of the medication cart unattended and out of sight. LPN #4 stated, No. Interview with the Unit Manager on 7/3/19 at 6:19 AM, at the Nurses' Station, the Unit Manager was asked should the nursing staff leave medications on top of the medication cart unattended and out of sight. The Unit Manager stated, No. The Unit Manager was asked should the medication carts have internals and externals in the same compartment on the medication cart. The Unit Manager stated, No.",2020-09-01
892,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2018-09-18,880,D,0,1,CU8L11,"**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 appropriate infection control practices were followed when signage for isolation was not posted for 1 of 1 (Resident #226) sampled residents observed in isolation and when 1 of 3 (Licensed Practical Nurse (LPN ) #1) nurses did not perform hand hygiene between glove use during medication administration observations. The findings included: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) 2012 documented, .Contact Precautions 1. In addition to Standard Precautions, Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires . Medical record review revealed Resident #226 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Interdisciplinary Notes dated 9/14/18 documented, .Today noted to have several loose slimy stools every attends change/4-5x (times). Medical Team alerted; will place on Contact isolation . Observations in Resident #226's room on 9/16/18 at 10:30 AM, 3:01 PM, 9/17/18 at 7:57 AM, 10:16 AM, 1:55 PM, and 9/18/18 at 8:08 AM, revealed a cart with personal protective equipment. There was no sign on the door indicating the resident was in isolation. Interview with LPN #1 on 9/17/18 at 1:45 PM at the Rehab Nurses' station, LPN #1 was asked if a resident was in contact isolation should there be a sign to be on the door to alert staff and visitors. LPN #1 stated, Yes. 2. The facility's Personal Protective Equipment (PPE) - Using Gloves policy revised (MONTH) 2010 documented, .Purpose To guide the use of gloves .Objectives 1. To prevent the spread of infection .3. To protect hands from potentially infectious material .Miscellaneous .5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . The facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7 .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Observations in front of the Rehab Nurses' station on 9/17/18 at 9:50 AM revealed LPN #1 washed her hands, applied gloves, prepared the medications for Resident #226, removed the gloves, entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to this resident. LPN #1 removed her gloves and applied new gloves without performing hand hygiene, checked gastrostomy tube placement, and administered medications through the gastrostomy tube. LPN #1 then removed the PPE and gloves and washed her hands. LPN #1 went to the medication cart, applied gloves, cleaned the bag containing the eye drops with a bleach wipe, removed her gloves, and obtained the next set of eye drops to administer to the resident. LPN #1 entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to the resident. Interview with the Director of Nursing (DON) on 9/18/18 at 10:35 AM, in the Senior Staff lounge, the DON was asked what nurses should be do after the removal of gloves and application of new gloves. The DON stated, Wash hands.",2020-09-01
893,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,159,D,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide access to resident personal funds after regular business hours and on weekends for 2 residents (#23, #13) of 32 residents with personal funds accounts. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired for daily decision making. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. Interview with Resident #23 on 2/27/17 at 12:14 PM, in the resident's room revealed money from Resident #23's personal funds account was not available on weekends. Interview with Resident #13 on 2/27/17 at 3:18 PM, in the resident's room revealed money from Resident #13's personal funds account was not available on weekends and was not available after 5:00 PM on weekdays. Interview with the Business Office Manager on 3/1/17 at 12:00 PM, in the Business Office Managers Office, confirmed the facility failed to provide access to resident personal funds after regular business hours on weekdays and on weekends.",2020-09-01
900,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,609,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interviews, the facility failed to report to the state agency allegations of abuse to include an injury of unknown origin for one resident (#4) of five sampled residents reviewed for allegations of abuse. The findings included: Review of the facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be reported to the Administrator, State Agency, law enforcement, the physician, and the resident and/or Power of Attorney. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Medical Director, who was also the attending physician, on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed, Later when I looked at the chest x-ray films, I thought I saw a foreign body on the films even though the chest x-ray report did not mention it so I ordered the KUB x-ray. I have no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB (x-ray of the abdomen) three times to verify that this was a screw and not an artifact. The resident had no pain or vomiting or change in bowel habits. Once I verified that it was a screw I admitted her to the hospital under the care of a [MEDICATION NAME]. The screw was removed without any adverse effect to the resident. The Medical Director stated Resident #4 had no prior history of putting non-food items in her mouth. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed the incident of Resident #4 having a screw in her abdomen was not reported. The DON stated a screw in the abdomen is an unusual finding and we should have reported it. Since she (Resident #4) didn't have any outcome we just didn't think to report it.",2020-09-01
901,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,610,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to investigate an injury of unknown origin for one resident (#4) of five sampled residents reviewed for abuse. The findings included: Review of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be investigated. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed no formal investigation had been done or documented. The DON stated the family was interviewed about Resident #4 possibly swallowing a screw prior to admission to the facility, staff were interviewed if Resident #4 had displayed any behavior of putting non-food items in her mouth, and the physician was interviewed. The DON stated the resident had no change in condition related to swallowing, pain or bowel movements. It (the screw) was discovered as a fluke on an x-ray. Interview with the Medical Director on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed he had no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB three times to verify that this was a screw and not an artifact. Once verified, I admitted the resident to the hospital under a [MEDICATION NAME] (physician specializing in the throat, stomach, and intestinal tract). The screw was removed without adverse effect to the resident. I had the staff check the resident's room and wheel chair for missing screws. None were found. Interview with the DON on 3/21/18 at 9:45 AM, in the conference room, confirmed, We did not write up an investigation.",2020-09-01
906,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,770,D,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain physician's ordered laboratory services for 1 resident (#60) of 6 residents reviewed for laboratory services of 18 sampled residents. The findings include: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders dated 4/1/19 - 4/30/19 revealed .Atorvastatin (medication to treat high cholesterol) .Levetiraceta (anticonvulsant) .[MEDICATION NAME] (antihypertensive) .[MEDICATION NAME] Sodium (nonsteroidal anti-[MEDICAL CONDITION] pain medication) .[MEDICATION NAME] (antidepressant) . Medical record review of the comprehensive care plan dated 10/4/18 and updated 1/10/19 and 4/11/19 revealed the resident had a potential for complications related to MS, HTN, and [MEDICAL CONDITION] with the approach .Monitor labs as ordered by physician . Medical record review of a Physician's Telephone Order dated 3/8/19 revealed laboratory (lab) orders for a complete blood count (CBC) and basic metabolic panel (BMP) .once . Medical record review revealed the CBC and BMP lab results for 3/8/19 were not on the resident's chart. Interview with the Registered Nurse (RN) #1 on 4/23/19 at 6:10 PM, at the nurse's station, confirmed the resident's CBC and BMP ordered on [DATE] was not obtained. Interview with the Director of Nursing (DON) on 4/24/19 at 12:10 PM, at the nurse's station, confirmed the facility failed to obtain the ordered lab services for Resident #60.",2020-09-01
909,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,604,D,0,1,VPQ611,"**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 assess 1 resident (#57) prior to the use of a physical restraint, and failed to assess 1 resident (#63) for restraint reduction of 3 residents reviewed for physical restraints. The findings included: Review of the facility policy, Use of Restraints, revised (MONTH) 2007, revealed .Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .Restrained individuals shall be reviewed regularly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination . Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed no documentation the restraint assessment had been completed prior to the use of bilateral 3/4 length side rails. Observation of the resident on 5/14/18 at 8:00 AM, in the resident's room, revealed the resident lying in bed with both 3/4 side rails in the up position. Observation of the resident on 5/14/18 at 12:00 PM, in the resident's room, revealed the resident sitting on the left side of the bed (with the left 3/4 length side rail down) eating lunch and the right side 3/4 rail was in the up position. Observation of the resident on 5/14/18 at 3:30 PM, in the resident's room, revealed the resident lying in the bed with both 3/4 side rails in the up position. Interview with the Registered Nurse (RN) Unit Manager #1 on 5/15/18 at 2:15 PM, in the resident's room, revealed the facility does not code side rails as restraints. Further interview revealed the resident was unable to transfer out of the bed or sit on the side of the bed due to the side rails. Further interview revealed the resident was able change positions from lying to sitting with no assistance. Further interview revealed the side rails were in place to keep the resident in the bed to prevent falls. Interview with the Director of Nursing on 5/15/18 at 3:15 PM, in the conference room, confirmed the side rails were used as a restraint and a restraint assessment had not been completed. She stated she was unaware that 3/4 side rails were being used in the facility. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physical Restraint Elimination assessment dated [DATE] and 5/15/18 revealed the resident was a good candidate for restraint reduction/elimination. Review of the Resident's Physical Restraint assessment dated [DATE] and reviewed on 5/15/18 revealed to continue with the .lap buddy ( a soft, cushion-type device that fits over the lap and may be secured in different ways depending on the manufacturer) due to decreased safety awareness. Resident with extreme decreased safety awareness - tolerating lap buddy well. Resident with history of Dementia, Depression, Mood Disorder . Continued review revealed the resident was a good candidate for restraint reduction or elimination. Review of Resident #63's care plan dated 11/10/17 and updated on 1/31/18 and 4/20/18 revealed the resident was to use a lap buddy while up in the wheelchair to stop unassisted ambulation. The care plan stated reassess for elimination of restraint or for change to less restrictive option routinely. The care plan stated the resident needed the lap buddy restraint due to poor safety awareness. Observation of Resident #63 on 5/14/18 on several occasions from 10:00 AM until 4:00 PM revealed the resident was up in the hallways and day room with the lap buddy in place. Observation of the resident on 5/15/18 on several occasions from 7:30 AM until 4:15 PM revealed the resident was up in the hallways and day room with the lap buddy in place. Interview with the Director of Nurses on 5/15/18 at 3:15 PM, in the conference room, confirmed no interventions to reduce the resident's use of a restraint had been attempted in quite a while.",2020-09-01
911,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,657,D,0,1,VPQ611,"**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 revise the care plan for 2 residents (#37, #39) of 21 residents reviewed. The findings included: Review of the facility's policy, Care Planning - Interdisciplinary Team, revised (MONTH) 2013, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].oxygen at 2 liters per minute, via nasal cannula (device used to administer oxygen through the nares of the nose) continuously . Review of the care plan dated 7/14/17 and updated 5/16/18, revealed the resident had a potential ineffective breathing pattern. Further review revealed the care plan had not been updated for the resident's refusal to wear the oxygen in the dining room. Observation of the Resident #37 on 5/16/18, at 8:00 AM, in the dining room, revealed the resident was up in a wheel chair without oxygen. Interview with the Registered Nurse (RN) Unit Manager #1 on 5/16/18, at 8:15 AM, in the dining room, confirmed the resident refused to wear the oxygen during meal times. Interview with the RN Unit Manager #1 on 5/16/18 at 8:30 AM, at the nurse's station, confirmed Resident #37 was not using the oxygen in the dining room, and the care plan had not been updated with the resident's refusal to use oxygen in the dining room. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of the resident on 5/16/18 at 9:00 AM, in the resident's room, revealed the resident was lying in the bed and the oxygen concentrator was next to the bed and turned off. Interview with the Registered Nurse (RN) Unit Manager #2 on 5/16/18, at 9:15 AM, in the resident's room, confirmed Resident #39's oxygen concentrator was not on and stated the resident was non-compliant with the oxygen use. Review of the care plan dated 3/6/18 and updated on 5/16/18 revealed the resident had a potential for an ineffective breathing pattern. Further review revealed the care plan had not been updated for the resident's non-compliance with oxygen use. Interview with the RN Unit Manager on 5/16/18, at at 9:30 AM, at the nurse's station, confirmed Resident #39's care plan had not been updated with the resident's non-compliance with oxygen.",2020-09-01
915,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,759,D,0,1,VPQ611,"**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 administer the correct dose of medication for 1 resident (#68). The facility had a total of 4 medication errors in 31 opportunities resulting in a medication error rate of 10%. The findings included: Review of the facility's policy, Administrating Medications, revised (MONTH) 2012, revealed .the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of a medication pass with Licensed Practical Nurse (LPN) #3 on 5/15/18 at 8:05 AM, in the 300 hallway revealed the LPN prepared Resident #68's medication for administration. Continued observation revealed the LPN did not check the prepackage medications with the Medication Administration Record. Further observation revealed the LPN removed medications from the packet and placed the medications into a cup. Continued observation revealed the LPN placed pudding into the cup and carried the cup to the door of the resident's room. At this time, the surveyor stopped the LPN before she administered the medications and obtained the Registered Nurse (RN) Unit Manager #1 to check the medications about to be administered. LPN #3 had placed the 8:00 AM dose for 5/15/18 and the 8:00 AM dose for 5/16/18 of the [MEDICATION NAME] XL (a diabetic medication) 2.5 milligram (mg) into the cup (1 extra dose). Further observation revealed the LPN had placed the 5/15/18 - 8:00 AM and 8:00 PM dose and the 5/16/18 - 8:00 AM dose of the [MEDICATION NAME] (a blood pressure medication) 50 mg into the cup (2 extra doses). Continued observation revealed the LPN had placed the Tamulosin (relaxes the muscle in the bladder) 0.4 mg capsule in the cup which was due on 5/15/18 at 8:00 PM. Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed the resident was ordered the following medications: [REDACTED]. Interview with LPN #3 and RN Unit Manager #1 on 5/15/18 at 8:15 AM, in the 300 hallway confirmed LPN #3 had failed to check the medications against the resident's Medication Administration Record [REDACTED].",2020-09-01
918,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,155,D,1,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on patient rights review, medical record review, and interview, the facility failed to allow 1 Resident (#59) of 32 residents reviewed the right to refuse dental services. The findings included: Review of the Patient Rights handbook provided to each resident in the facility revealed, .You have the right to accept or refuse any medication or treatment .You are entitled to explore various options available to you and to choose the treatment option you prefer . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Telephone interview with Resident #59's family conservator on 6/28/17 at 12:53 PM revealed she had revoked her consent for dental care in (YEAR). Continued interview revealed she had verbalized this to the Social Worker (SW) who stated she would call the dental office and tell them to take the resident off the list to be seen at the facility. Continued interview revealed the family conservator learned the resident received dental services on 1/5/17 after receiving a bill from the dental clinic. She called the facility and spoke with the SW and was told she would call the dental clinic again and make sure the resident was no longer on the list for cleanings or any further dental care. Medical record review revealed a Dental Progress Note dated 1/5/17 indicating that a dental exam, cleaning, and x-rays had been completed by the dental clinic for Resident #59. Interview with the SW on 6/28/17 at 2:05 PM in the classroom confirmed the family conservator had requested no dental services to be performed for the resident. Continued interview revealed the resident was placed on the exam list by the dental clinic in error, and the resident did receive dental services on 1/5/17. The SW stated, I just overlooked her being on the list when he showed it to me. The SW confirmed the facility failed to honor the resident's right to refuse dental services.",2020-09-01
919,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,164,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to provide privacy for 2 residents (#127, #154) of 8 residents observed during blood glucose monitoring and medication administration. The findings included: Review of facility policy, Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, dated 6/2016 revealed .16) The privacy of the resident is maintained as needed during the administration of medications . Medical record review revealed Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 6/26/17 at 5:00 PM in room [ROOM NUMBER] revealed Licensed Practical Nurse (LPN) #1 performing blood glucose monitoring for Resident #127. Continued observation of the resident revealed the resident sitting in a wheelchair in the middle of her private room angled toward the door. The LPN performed the blood glucose monitoring while the door was still open to the hallway. Interview with the LPN when asked if she usually closed the door or provided privacy, revealed I usually do. Continued interview revealed when asked if she should provide privacy to residents during procedures revealed yes. LPN #1 confirmed she did not provide privacy for Resident #127 while performing blood glucose monitoring. Medical record review revealed Resident #154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 6/27/17 at 8:56 AM in room [ROOM NUMBER] B revealed Registered Nurse (RN) #1 administering medications via feeding tube to Resident #154. Continued observation revealed the door and the privacy curtain between A and B bed were open. The resident in A bed was in the room in her wheelchair. Further observation revealed the RN exposed the resident's abdomen and when asked if the privacy curtain should be pulled stated yes it should. The RN confirmed she did not provide privacy to Resident #154 prior to exposing the resident. Interview with the Director of Nursing (DON) on 6/28/17 at 11:47 AM in the classroom revealed when asked if she expected nursing staff to provide privacy during procedures and medication administration stated yes. Continued interview with the DON confirmed staff was to provide privacy to residents during procedures and medication administration. Further interview confirmed the facility failed to provide privacy during blood glucose monitoring and medication administration.",2020-09-01
920,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,241,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility staff failed to treat 2 residents (#94, #131) of 11 residents observed with dignity by standing over the two residents while assisting them to eat. The findings included: Review of facility policy, Assistance with meals, revised (MONTH) 2013 revealed .Residents who cannot feed themselves will be fed with attention to .dignity, for example: (1) Not standing over residents while assisting them with meals . Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #94's cognitive patterns could not be assessed because the resident was rarely or never understood. Review of the Activities of Daily Living (ADL) care plan dated 3/1/17 and updated 5/16/17 revealed Resident #94 required assistance with ADLs with an intervention to assist the resident with meals as needed. Observation on 6/26/17 at 12:50 PM in the 100/200 hall assisted dining room revealed Licensed Practical Nurse (LPN) #3 was standing over Resident #94 while assisting the resident with dining. Interview with LPN #3 at 12:50 PM in the 100/200 hall assisted dining room revealed it was not the facility's practice for staff to stand while assisting residents with dining. Continued interview with the LPN confirmed the facility failed to treat Resident #94 with dignity when the staff member stood over the resident while assisting the resident with dining. Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident required extensive assistance with meals. Observation of the lunch service on 6/26/17 at 1:03 PM in the assisted dining room on the 300 and 400 hall revealed LPN #2 standing while assisting Resident #131 with dining. Interview with LPN #2 at 3:00 PM at the 400 hall medication cart revealed when asked if he normally stood to assist residents with meals stated, I was just there for a few minutes to help out. Continued interview revealed when asked if it was an appropriate procedure to stand while assisting residents with meals, the LPN stated no. LPN #2 confirmed he failed to treat the resident with dignity while standing to assist the resident with dining.",2020-09-01
921,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,278,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for 2 residents (#59, #79) of 32 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not assessed to receive hospice services. Interview with the MDS Coordinator on 6/28/17 at 4:00 PM in the MDS office confirmed the facility failed to accurately assess Resident #59's status for hospice services. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/17 at 2:40 PM in Resident #71's room revealed the resident's top dentures moved up and down as she talked. Medical record review of the Annual MDS dated [DATE] revealed the oral/dental status section was coded as none of the above were present indicating the resident had no dental concerns. Telephone interview with Resident #71's daughter on 6/26/17 at 4:00 PM revealed she was aware her mother's dentures were too big due to weight loss. Continued interview revealed her mother was on end of life care and did not want to put her through having to have another denture fitting. Interview with the 300-400 hall Unit Manager on 6/28/17 at 9:49 AM in room [ROOM NUMBER] confirmed staff knew of the resident's loosely fitting dentures. Interview with the MDS Coordinator on 6/28/17 at 4:10 PM in the MDS office confirned she was aware of the resident's loosely fitting dentures. Continued interview revealed the MDS coordinator confirmed the facility failed to accurately assess the resident's loose fitting dentures on the Annual MDS dated [DATE].",2020-09-01
922,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,282,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan and follow interventions for 1 Resident (#25) of 32 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #25 had non-injury falls to occur on 4/1/17, 4/21/17, 4/25/17, 4/30/17, and 5/2/17. Medical record review of the care plan updated 5/16/17 revealed no interventions were initiated after the 4/21/17, 4/25/17, 4/30/17, and 5/2/17 falls. Medical record review of the care plan updated on 5/26/17 revealed the resident was to have assistance of 2 with transfers, a gait belt and a bathroom door alarm. Review of the facility Fall Investigation dated 5/2/17 revealed .Pt was toileted by CNA (certified nursing assistant) and after pt (patient) was placed back in w/c (wheelchair) and alarms were not turned back on. CNA was written up and all interventions were in place . Medical record review of the care plan updated 5/16/17 revealed no interventions were initiated after the 5/2/17 fall. Medical record review of the care plan updated 5/26/17 revealed the resident was to have assistance of 2 with transfers and a gait belt, and a bathroom door alarm. Observation and interview with CNA #1 on 6/28/17 at 4:54 PM at the door to the resident's room revealed when asked about a bathroom door alarm, explained there is one on the door, but it is never on. Continued observation with the CNA present revealed the bathroom door alarm was in the off position. Continued interview revealed the CNA stated We don't turn it on because we have to take her to the bathroom. When asked if she had ever seen the bathroom alarm on she stated No. That's not for these residents. Interview with Licensed Practical Nurse (LPN) #1 on 6/28/17 at 4:58 PM in room [ROOM NUMBER] revealed when asked about the bathroom door alarm LPN #1 stated there was a bathroom door alarm on the bathroom door but it is not on. I'm not sure why it's there. LPN #1 confirmed the bathroom door alarm was not in the working position and the facility failed to follow the care plan. Interview with CNA #1 on 6/28/17 at 5:40 PM in the split between 100-200 halls revealed she had just gotten the resident up and assisted her with the meal. The CNA was asked how much assist the resident required, she replied I do her by myself. Continued interview revealed she could get her up, transfer, toilet, and bathe the resident by herself. Interview with the Director of Nursing (DON) on 6/28/17 at 6:38 PM at the 100-200 hall nurse's station revealed when the DON was asked if the current interventions on the care plan should be in place, the DON stated yes, if it is on the current care plan it should be done. Continued interview revealed when asked about the bathroom door alarm, and assist of 2 for the resident, the DON confirmed those interventions should be done. Continued interview revealed when the DON was asked if the care plan should be updated after each fall the DON stated yes. Interview with the DON confirmed the facility failed to update the care plan after each of the resident's falls and failed to follow the care plan interventions.",2020-09-01
924,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,441,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to wash or sanitize the hands and don gloves prior to entering 1 contact isolation room (#102) while delivering meal trays, and failed to wash or sanitize the hands while exiting the room for 14 meal trays observed on the 100 hall. The findings included: Review of facility policy, Transmission Based Procedures, revised 10/1/08 revealed, .use Contact precautions for patients known or suspected to be infected or colonized with epidemiologically significant microorganisms that can be transmitted by direct contact with the patient or indirect contact with the environmental surfaces .In addition to wearing gloves .remove gloves before leaving room and wash hands immediately with an antimicrobial agent . Observation on 6/26/17 at 12:17 PM on the 100 hall revealed Certified Nurse Aide (CNA) #2 entering room [ROOM NUMBER] carrying disposable meal containers. Isolation personal protective equipment was noted hanging on the outside of the door to the room. Continued observation revealed the CNA did not wash or sanitize the hands or don gloves prior to entering the room. Continued observation revealed the CNA moved items on the resident's over bed table and placed the disposable meal containers on the over bed table and exited the room without washing or sanitizing the hands. Interview with CNA #2 on 6/26/17 at 12:18 PM in the 100 hall when asked if the resident in room [ROOM NUMBER] was on contact isolation stated, Yes, he has MRSA (bacterial infection that is resistant to numerous antibiotics). Continued interview with the CNA revealed when asked why she did not wash or sanitize her hands or don gloves upon entering the room or wash her hands prior to exiting the room stated, I forgot. Interview with the Director of Nursing (DON) on 6/26/17 at 4:00 PM in the hallway by the ADON's (Assistant DON's) office confirmed washing hands, and donning gloves before and after entering an isolation room was the expectation of all staff. The DON confirmed the facility failed to follow standard infection control practices for handwashing.",2020-09-01
925,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,638,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#1) of 38 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 had a Quarterly MDS completed on 3/19/19. Further medical record review revealed no Quarterly MDS was completed in (MONTH) 2019. Interview on 7/9/19 with Registered Nurse (RN) #1, MDS Coordinator at 4:43 PM in her office revealed Resident #1 had not had a Quarterly MDS completed since (MONTH) 2019. When asked when the MDS assessment was due for Resident #1 the MDS Coordinator confirmed, The Quarterly MDS was due on (MONTH) 19, 2019 and I missed it.",2020-09-01
926,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,657,D,0,1,YQNG11,"**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 revise/update care plans for 2 (#55 and #237) of 38 residents reviewed. The findings include: Review of the facility policy, Care Plan Development, revised 7/3/08 revealed .Care Plans are updated as needed, but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of completion .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 . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was always incontinent of bladder and bowel. Medical record review of the Admission Observation dated 7/2/19 revealed Resident #55 was admitted with an indwelling catheter. Observation on 7/8/19, 7/9/19, and 7/10/19 in Resident #55's room revealed the resident's catheter bag was in a dignity bag on the side of the bed. Interview with Registered Nurse #5 (RN) on 7/10/19 at 11:50 AM at the nurse station revealed the staff nurses, MDS coordinator and Unit Managers could update the care plans. Continued interview revealed when asked what the date on the care plan was RN #5 responded .7/10/19 . Continued interview revealed when asked when it would be appropriate to update the care plan she replied .If I see a new care order I would update the care plan . Interview with the Director of Nursing (DON) on 7/10/19 at 6:10 PM in the conference room revealed care plans are completed on admission. Continued interview revealed the MDS coordinator completed the comprehensive care plan after the 1st Resident Assessment Instrument (RAI) assessment. Interview with the MDS Coordinator on 7/10/19 at 6:23 PM in her office revealed the care plan was not updated until after an assessment. Continued interview revealed nurses were responsible for updating the care plan when a resident was admitted to the facility. Interview with LPN #6 also known as the Unit Manager on 7/10/19 at 6:30 PM in the conference room confirmed .Normally it (catheter) should be put on admission. I don't know why it was missed . Interview with the DON on 7/10/19 at 6:44 PM in the hall by the conference room when asked to review Resident #55's care plan she confirmed .I will be honest with you, if it's (catheter) not there we forgot to do it . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's Admission MDS dated [DATE] revealed the resident had no venous or arterial ulcers. Medical record review of Resident #237's 14 day MDS dated [DATE] revealed the resident had 1 venous and arterial ulcer present. Medical record review of the Physician Orders for Resident #237 revealed .5/1/19 .Right LAT.(Lateral) ANKLE - (SCAB REMOVAL FROM ABRASION) .CLEANSE WITH WOUND WASH &(And) PAT DRY .APPLY SKIN PREP COVER WITH MEDIUM ALLEVYN-DAILY .5/6/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING EVERY MON (Monday)/WED (Wednesday)/FRI (Friday) .5/10/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY BIOSTEP TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING DAILY .RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .PRN (As needed) .CLEANSE WITH WOUND WASH & PAT DRY. APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING AS NEEDED DUE TO ACCIDENTAL REMOVAL/LOOSE/SOILED .6/18/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY ZINC OINTMENT TO PERI-WOUND .APPLY THICK LAYER OF SANTYL TO WOUND BED .LARGE [MEDICATION NAME] .CHANGE DRESSING - EACH SHIFT .Day 7:00 AM .Night 7:00 PM .FLOAT ANKLES/HEELS . Medical Record Review of Resident #237's comprehensive care plan dated 3/29/2019 - 7/10/2019 revealed .alteration in/potential for alteration in skin integrity R/T (related to)[MEDICAL CONDITION] with right sided weakness . Continued review revealed the resident had no wounds to the right lateral ankle. Interview with the DON on 7/11/19 at 11:51 AM in the conference room when asked to look at the care plans for Resident #237, she stated There's nothing in here that addresses the ankle. Continued interview with the DON confirmed Resident #237's care plan was not updated, she stated any nurse receiving orders should update the care plan with what the orders reflect and (named resident) was not.",2020-09-01
927,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,690,D,0,1,YQNG11,"**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 timely for placement of an indwelling catheter for 1 (#55) of 38 residents reviewed. The findings include: Review of the facility policy, Medication Orders, dated 6/2016 revealed .Medications are administered only upon an order from a person lawfully authorized to prescribe . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the History of Present Illness dated 6/28/19 revealed .had evidence of a acute kidney injury .was found to have acute [MEDICAL CONDITION] by bladder scan .Foley catheter was placed with 1200 ml (milliter) of urine returned . Medical record review of the Physician Orders for Resident #55 dated 7/5/19 revealed .Change Indwelling Catheter every 30 days once a day on the 1st month .Catheter Care Once per shift and document . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 required an indwelling catheter. Interview with Licensed Practical Nurse #6 also known as the Unit Manager on 7/11/19 at 11:55 AM in his office revealed .normally the staff nurses would put the orders in on admission . Interview with the Director of Nursing on 7/11/19 at 12:32 PM in the conference room revealed it was a night shift admission and the information did not get relayed appropriately. Continued interview confirmed .any of the nurses could have gotten an order and put it in. It should have been in place .",2020-09-01
928,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,695,D,0,1,YQNG11,"**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 label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 (#71) of 20 residents reviewed receiving respiratory treatments. The findings include: Facility policy review, Supplemental Oxygen, dated 1/2005, revealed .the purpose of delivering oxygen by nasal cannula is to: correct [MEDICAL CONDITION] (low oxygen) by increasing available alveolar oxygen .Diminish the [MEDICAL CONDITION] (heart) work load by correcting hypoxemia (low level of oxygen in the blood) .decrease in breathing efforts to maintain adequate oxygenation .infection can occur if equipment is not changed and cleaned properly .change tubing and cannula every 7 days .label each tubing with date, and your initial .change humidifier when empty or at least weekly and date . Facility policy review, Aerosol Therapy, revised 7/2014, revealed .intermittent Aerosol with Medication Administration with medication is used to deliver fine particles of liquid and medication in the [MEDICATION NAME] tree .this means of medication administration is quick and has few systemic side effects .Intermittent aerosol with medication administration is indicated for [MEDICAL CONDITION] such as asthma or [MEDICAL CONDITION] .be sure nebulizer and tubing are labeled with the date and initial .nebulizer can become contaminated resulting in an infection .change nebulizer and tubing every 7 days . Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #71's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident received oxygen therapy. Medical record review of Resident #71's physician orders [REDACTED].oxygen (02) 2 liters per minute via nasal cannula continuous .6/14/19 [MEDICATION NAME] (a medication used to open the airway) solution for nebulization 0.5 milligram (mg) - 3 mg (2.5 mg base)/3 milliliter (ml) 1 inhalation every 6 hours (hr) as needed .[MEDICAL CONDITIONS] . Medical record review of Resident #71's comprehensive care plan dated 6/26/19 revealed .Respiratory complications: at risk for R/T (related to) [MEDICAL CONDITION] 02 dependent .Administer 02 at [MEDICAL CONDITION] (positive air pressure machine to treat sleep apnea) at hour of sleep as ordered neb (nebulizer) treatments as ordered 02 as ordered .administer [MEDICATION NAME][MEDICATION NAME] . Observation on 07/08/19 at 10:56 AM and at 4:22 PM in Resident #71's room revealed the resident receiving 02 via (by) nasal cannula at 2 liters per minute. Continued observation revealed a nebulizer machine (a machine used to deliver aerosol treatments) on the resident's bedside table not in use. Continued observation revealed the oxygen tubing, humidified water bottle and the nebulizer tubing were dated 6/27/19. Interview with the Central Supply Nursing Assistant on 7/8/19 at 4:38 PM in her office revealed she was responsible for changing the residents' oxygen tubing, humidified water bottles and nebulizer tubing. Continued interview revealed oxygen tubing, nebulizer tubing and humidified water were changed weekly. Observation and interview with the Central Supply Nursing Assistant on 7/8/19 at 4:40 PM in Resident #71's room when asked to look at the resident's tubings and humidified water bottle she confirmed the tubings and bottle were dated 6/27/19. Continued interview she stated I thought I changed these Friday (July 5 2019); I did not do (named resident), (named resident) was the last one, (named resident) was in the shower; I meant to go back and change them and I did not. Observation and interview with the Director of Nursing on 7/8/19 at 4:58 PM in the Resident #71's room confirmed the resident's oxygen tubing, nebulizer tubing and humidified water bottle were dated 6/27/19. Continued interview she stated the bottle and tubings were to be changed weekly by the Central Supply Nursing Assistant.",2020-09-01
929,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,711,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure the attending physician visit included an evaluation of the resident's total program of care including medications, treatments and a decision about continued appropriateness for current medical regimen for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #237's physician visit note dated 4/1/19 revealed, .No Ulcer/Rash/Petechia/Purpura/Masses/or other [MEDICAL CONDITION] . Medical record review of Resident #237 Resident Progress Notes by the NP (Nurse Practitioner) dated 4/4/19 revealed, .Ext (Extremities): No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/11/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Medical record review of Resident#237's Reesident Progress Notes by the NP dated 4/18/19 revealed, .Ext: No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/25/19 revealed, .Skin: see nursing notes . Medical record review of Resident #237's Resident Progress Notes by the PA (Physician's Assistant) dated 4/30/19 revealed, .Skin: warm and dry . Medical record review of Resident #237's physician visit note dated 5/27/19 revealed skin assessment not performed. Medical record review of Resident #237's Resident Progress Notes by the NP dated 6/13/19 revealed, .wound care following skin break down on penis .skin: see wound care notes . Medical record review of Resident #237's Resident Progress Notes by the PA dated 6/21/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed the resident did not have a [DIAGNOSES REDACTED]. Continued interview when asked if Resident's #237's right [MEDICAL CONDITION] could have been prevented he stated, It's hard to tell; possibly if the resident had a Doppler done of the extremity (named resident) could have went to a vascular surgeon for an angioplasty. Further interview when asked if he had assessed Resident #237's wound he confirmed, I never saw the resident. Interview with the Administrator with the Director of Nursing present on 7/10/19 at 7:20 PM in the conference room revealed when asked if Resident #237's attending physician assessed Resident #237's wound during his visit he stated, He signed the orders, I leave the assessments to the nursing department and the Director of Nursing.",2020-09-01
930,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,712,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review, facility policy review and interview the facility failed to ensure timely physician visits were performed for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's physician visit notes dated 4/1/19 revealed the resident was seen by the physician. Medical record review of Resident #237's physician visit notes dated 5/27/19 revealed the resident was seen by the physician. Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed when asked if he had assessed Resident #237 he confirmed, I never saw the resident.",2020-09-01
931,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2018-07-18,584,D,0,1,B25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to replace and repair the baseboards for 1 of 14 rooms (room [ROOM NUMBER]) on the 400 hall reviewed. Findings include: Observation on 7/16/18 at 9:30 AM, 7/17/18 at 10:36 AM, and 7/18/18 at 8:08 AM, in room [ROOM NUMBER] on the 400 hall revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Observation on 7/18/18 at 5:09 PM, with the Director of Nursing (DON), in room [ROOM NUMBER] revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Interview with the DON on 7/18/18 at 5:44 PM in room [ROOM NUMBER] confirmed the facility failed to replace and repair the baseboards in room [ROOM NUMBER].",2020-09-01
932,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2018-07-18,676,D,0,1,B25G11,"**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 ensure 1 of 34 residents (Resident #294) reviewed, had clean and groomed finger nails. Findings include: Review of facility policy Fingernails, Cleaning and Trimming, undated, revealed .Designated partner will care for patients nails daily and PRN (as needed) .clean around and under the nails . Medical record review revealed Resident #294 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #294's comprehensive care plan dated 7/12/18 revealed the resident required assistance with activities of daily living. Continued review of the care plan revealed .Check, clean, and trim nails as needed and to keep nails short . Observations of Resident #294 on 7/16/18 at 11:16 AM, 12:47 PM, and 4:41 PM in the residents room revealed the resident's fingernails were long, chipped, and had brown debris under the nails on both hands. Interview with the Director of Nursing (DON) on 7/16/18 at 4:41 PM in Resident #294's room confirmed the resident's nails were uncleaned and ungroomed. The DON looked at Resident #294's nails and stated You're in need of a trim. Further interview with DON revealed resident nail care was to be performed during showers and as needed.",2020-09-01
934,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,640,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility to complete and transmit an MDS assessment within 14 days of the completion date for 1 of 38 sampled residents (Resident #2) reviewed for Resident Assessment and transmission. The finding include: Review of the MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 664, showed, .Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment, showed the assessment had an Assessment Reference Date of 1/10/2020 and a completion date of 1/24/2020. The annual assessment should have been transmitted by 2/7/2020, but had not been transmitted. During an interview conducted on 2/20/2020 at 6:55 PM, MDS Coordinator #1 stated, .(Resident #2's MDS) didn't get transmitted .got over looked .",2020-09-01
935,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,641,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for bladder and bowel continence, activities of daily living, cognition, and the use of antipsychotics for 4 of 38 sampled residents (Resident #10, #62, #87, and #104) reviewed. The findings include: 1. Review of the medical record, showed Resident #10 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #10 was frequently incontinent of bladder and bowel. Review of the annual MDS dated [DATE], showed Resident #10 was always incontinent of bladder and bowel. Review of the Care Plan dated 11/25/2019, showed, .(Named Resident #10) is incontinent of bowel and bladder r/t (related to) impaired mobility and cognitive deficit . During an interview conducted on 2/20/2020 at 2:13 PM, MDS Coordinator #2 confirmed the MDS dated [DATE] was coded incorrectly for bladder and bowel, and stated, .she (Resident #10) is always incontinent . 2. Review of the medical record, showed Resident #62 had [DIAGNOSES REDACTED]. Review of the Care Plan dated 8/19/16 and revised 10/8/2019 showed, .I am at risk for alteration of ADL's (Activities of Daily Living) r/t limited mobility .[MEDICAL CONDITION] r/[MEDICAL CONDITION] .Transfer (Named) Lift and large sling .Staff performs all ADL's . Review of the quarterly MDS dated [DATE] showed, Resident #62 was extensive assist for bed mobility. During an interview conducted on 2/20/2020 at 2:23 PM, MDS Coordinator #3 confirmed the MDS dated [DATE] was coded incorrectly for bed mobility, and stated, .she (Resident #62) has always been total care . 3. Review of the medical record, showed Resident #87 had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], showed Section C (Cognitive Patterns) was not completed. During an interview conducted on 2/20/2020 at 6:48 PM, MDS Coordinator #1 confirmed Section C, Cognitive Patterns had not been completed. 4. Review of the medical record, showed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the quarterly MDS dated [DATE], showed in Section N0410A that antipsychotic medications were received for the last 7 days and in Section N0450A that antipsychotic medications were not received. During an interview conducted on 2/20/2020 at 2:43 PM, MDS Coordinator #2 confirmed the MDS dated [DATE] was coded incorrectly for antipsychotics, and stated, That's a contradiction.",2020-09-01
936,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,689,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement fall interventions for 2 of 5 sampled residents (Resident #71 and #135) reviewed for falls. The findings include: 1. Review of the medical record, showed Resident #71 had [DIAGNOSES REDACTED]. Review of the Care Plan revised 1/15/2020, showed, .Problem .has the potential for falls and fall related injuries r/t (related to) poor safety awareness .Approaches .1/15/20 (2020) .dycem (cushion that prevents sliding) to w/c (wheelchair) . Observation in the resident's room on 2/20/2020 at 3:50 PM, showed there was no dycem in Resident #71's wheelchair. During an interview conducted on 2/20/2020 at 3:50 PM, Licensed Practical Nurse (LPN) #1 confirmed there was no dycem in Resident #71's wheelchair. 2. Review of the medical record, showed Resident #71 had [DIAGNOSES REDACTED]. Review of the Care Plan revised 12/14/2019, showed, .Problem .is at risk for falls .Approaches .12/14/2019 .Landing mat to Left side of bed . Observation in the resident's room on 2/18/2020 at 3:50 PM, 2/19/2020 at 7:55 AM and 5:04 PM, 2/20/2020 at 7:44 AM and 10:11 AM, and 2/21/2020 at 7:57 AM, showed there was no landing mat on the floor to the left side of Resident #71's bed. During an interview conducted on 2/21/2020 at 8:45 AM, LPN #2 confirmed there was no landing mat in his room. LPN #2 was asked if interventions on the Care Plan should be followed. LPN #2 stated, Yes, suppose to follow interventions on the Care Plan .",2020-09-01
937,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,690,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents (Resident #103) reviewed for the use of an indwelling urinary catheters. The findings include: Review of the medical record, showed Resident #103 had [DIAGNOSES REDACTED]. Review of the (MONTH) 2020 Physician Orders, showed, .MAINTAIN PATENCY AND PLACEMENT OF #18FR (FRENCH) / 10CC (CUBIC CENTIMETERS) BULB INDWELLING FOLEY CATHETER EVERY SHIFT .FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT . Review of the (MONTH) 2020 Medication Administration Record [REDACTED]. Review of the (MONTH) 2020 MAR, showed no documentation for catheter care for an indwelling urinary catheter from 2/8/2020 to 2/20/2020 on the 7:00 AM to 7:00 PM shift and on 2/12/2020, 2/13/2020, 2/14/2020, 2/16/2020, 2/17/2020, and 2/19/2020 on the 7:00 PM to 7:00 AM shift. Observation in the resident's room on 2/18/2020 at 4:37 PM, 2/19/2020 at 4:56 PM, and 2/20/2020 at 7:48 AM, showed Resident #103 had an indwelling urinary catheter. During an interview conducted on 2/21/2020 at 2:45 PM, the Interim Director of Nursing (DON) confirmed that nursing staff should have documented maintenance and placement for the use of an indwelling urinary catheter and should have documented indwelling urinary catheter care every shift as ordered.",2020-09-01
943,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,640,D,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete and transmit MDS assessments timely for 2 of 53 (Resident #4 and 6) residents reviewed for Resident Assessment and transmission. The finding include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 664 documented, . Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a discharge MDS assessment with an ARD of 11/1/18 and a completion date of 11/7/18. The discharge MDS assessment should have been transmitted by 11/21/18 but had not been transmitted. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a discharge MDS assessment with an ARD of 11/21/18 and a completion date of 12/5/18. The discharge assessment should have been transmitted by 12/19/19 but had not been transmitted. Interview with MDS Coordinator #1 on 4/3/19 at 4:05 PM, in the MDS Office, MDS Coordinator #1 was asked if the Discharge assessment dated [DATE] for Resident #6 should have been transmitted. MDS Coordinator #1 stated, I don't know why it wasn't. MDS Coordinator #1 was asked if the Discharge assessment dated [DATE] on Resident #4 should have been transmitted. MDS Coordinator #1 stated, Yes. Interview with the Director of Nursing (DON) on 4/3/19 at 4:50 PM, in the Conference Room, the DON was asked if she expected the MDS to be completed and transmitted timely. The DON stated, I do.",2020-09-01
944,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,656,D,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, policy review, medical record review, and interview, the facility failed to complete a comprehensive care plan for 1 of 33 (Resident #171) sampled residents reviewed. The findings include: The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 43-44 documented, .The Admission assessment is a comprehensive assessment .that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z0500B) must be no later than day 14 .The CAA (Care Area Assessment)(s) completion date (Item V0200B2) must be no later than day 14 .The care plan completion date (Item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (Item V0200B2) (CAA(s) completion date + 7 calendar days) . The facility's Comprehensive Person Centered Care Plans policy documented, .The Comprehensive Person Centered Care Plan shall be fully developed within 7 days after completion of the Admission MDS Assessment . Medical record review revealed Resident #171 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive care plan should have been developed by 2/12/19. The facility was unable to provide a comprehensive care plan for Resident #171. Interview with Licensed Practical Nurse (LPN) #1 on 4/3/19 at 5:30 PM, LPN #1 was asked if Resident #171 had a comprehensive care plan. LPN #1 stated, No.",2020-09-01
945,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2018-01-22,758,D,0,1,JYC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to determine a stop date for PRN (as needed) [MEDICAL CONDITION] medications for 1 of 5 sampled residents (Resident #64) reviewed prescribed [MEDICAL CONDITION] medications. Findings include: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED]. Continued review revealed an order dated 11/2/17 for [MEDICATION NAME] (antidepressant also used for [MEDICAL CONDITION]) 50 mg by mouth at bedtime PRN for depression, (sleeplessness) with no stop date. Interview with the Director of Nursing on 1/22/18 at 12:00 PM in the conference room confirmed the facility failed to determine a stop date for PRN [MEDICAL CONDITION] medications for Resident #64.",2020-09-01
946,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2018-01-22,812,D,0,1,JYC211,"Based on facility policy review, observation and interview, the facility failed to maintain 2 of 4 resident refrigerators and 2 of 3 ice machines in a sanitary manner. The findings included: Review of facility policy, unnamed, dated 9/2016 revealed, .Refrigerators in the Nursing Stations will be kept clean, free of debris, and mopped with sanitizing solution on a weekly basis and more often as necessary . Observation and interview on 1/18/18 at 12:26 AM in the 2nd Floor Nourishment Room with the Registered Nurse (RN) #1/Unit Manager present revealed brown dried debri on the shelves and door of the resident refrigerator. Continued observation of the ice machine on the interior upper portion revealed black debri. Interview with the Unit Manager confirmed the facility failed to maintain the resident refrigerator and the ice machine in a sanitary manner. Observation and interview on 1/18/18 at 12:29 PM in the 3rd Floor Nourishment Room with the RN #1/Unit Manager present revealed dried brown liquid on the shelves of the resident refrigerator. Further observation of the ice machine on the interior upper portion revealed black debri. Interview with the Unit Manager confirmed the facility failed to maintain the resident refrigerator and the ice machine in a sanitary manner.",2020-09-01
949,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-01-30,880,D,0,1,V3LN11,"**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 have appropriate signage for transmission-based precautions for 1 (#9) of 21 residents reviewed on transmission-based precautions. The findings include: Review of the facility policy, Isolation, dated 10/2016 revealed .Transmission-Based Precautions shall be used when caring for resident who are documented or suspected to have communicable diseases .Signs--use coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .place a sign at the doorway . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 had an infection requiring transmission based precautions. Medical record review of a comprehensive care plan dated 1/24/19 revealed Resident #9 was monitored and assessed for transmission based precautions both contact and droplet. Continued review revealed the transmission based precautions were for[DIAGNOSES REDACTED] and CRPA, respectively. Observation of Resident #9's doorway on 1/28/19 at 5:37 AM and 3:10 PM on the 3rd floor west hall revealed no signage identifying transmission based precautions required. Interview with Licensed Practical Nurse (LPN) #1 on 1/28/19 at 5:37 AM at the 3rd floor west hall medication cart confirmed Resident #9 was on contact and droplet transmission based precautions for[DIAGNOSES REDACTED] and CRPA respectively. Interview with LPN #4 and Registered Nurse (RN) #1 on 1/28/19 at 3:10 PM in the 3rd floor west hall confirmed no signage to indicate transmission based precautions was present on Resident #9's doorway.",2020-09-01
950,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,221,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure 1 resident (#4) of 11 residents reviewed was free of a physical restraint unless it was needed to treat an assessed medical symptom. Resident #4 was restrained in bed through the use of 4 side rails. The restraint was used without assessment for its need, without less restrictive measures attempted prior to its use, without a medical symptom justifying the use of the restraint, and without a physician's orders [REDACTED]. The findings included: Review of facility policy, Restraint Management, revealed Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff conveniences or for the prevention of falls. Physical restraints include, but are not limited to .side rails. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using side rails that keep a resident from voluntarily getting out of bed. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom; b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well being. Prior to applying a restraint, one must have an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MDS revealed Resident #4 required extensive assistance from staff with bed mobility, transfers, and locomotion, and had no restraints. Review of the medical record revealed no evidence of Physician Orders, Assessment, or Consent for the use of a restraint. Continued review revealed no evidence of an assessment for the use of side rails. Review of the current care plan, with a goal date of 10/17/17, revealed conflicting information about the use of side rails. Review of the Care Plan revealed Self Care Deficit, with approaches including, 7/4/17 .1/4 (one quarter) length side rails up times 2 when in bed to enable participation with bed mobility. However, review of the Care Plan for Fall Risk revealed an approach dated 7/26/17 Staff to ensure placement and raising of lower bedrail to amputation side of the bed in order to assist with safety during sleep. Note: (Resident #4) will still be able to get OOB (out of bed) to her strong side. Observation on 9/18/17 at 8:35 AM and 1:49 PM revealed Resident #4 was asleep in bed. She had 2 one half side rails raised on each side of the bed. The use of these 4 partial rails resulted in the effect of 2 full side rails which blocked normal egress from the bed. Interview on 9/18/17 at 1:52 PM with Certified Nurse Aide (CNA) #3, in the hallway outside the resident's room, confirmed the resident had 4 side rails up while she was asleep in bed. CNA #3 stated she always used all 4 side rails when Resident #4 was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the use of the 4 side rails restricted the resident's normal movement of exit/entry from the bed, as she stated, Just last week, I found her sliding out the end of the bed when all 4 side rails were raised. Interview on 9/18/17 at 1:55 PM with Licensed Practical Nurse (LPN) #1, in the hallway outside the resident's room, revealed staff were only supposed to use 2 side rails, because if they used all 4 side rails, It would be a restraint. CNA #3, who was present during this interview, confirmed all 4 side rails would constitute a restraint, saying, That's right. However, CNA #3 added, I was told to use all 4 because she's a fall risk. Interview with the Director of Nursing (DON) on 9/18/17 at 2:10 PM, in the first floor administrative wing confirmed, We have not historically done any assessment for side rails. She stated the facility was in the process of adding this to the admission packet, but confirmed no side rail or restraint assessments had been completed for Resident #4. The DON stated 4 side rails constituted a restraint for Resident #4, based on her physical condition. Further interview with the DON revealed she was unaware staff were using all 4 side rails when the resident was in bed, and the resident had no medical symptom to justify the use of a restraint.",2020-09-01
951,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,223,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of a Tek-Care Report and interview, the facility failed to prevent Verbal Abuse for 1 resident (#5) and Neglect for 1 resident (#6) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention, revised 4/1/17 revealed, .Abuse .will not be tolerated by anyone, including staff .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure the care is provided as needed for the resident .Verbal Abuse: The use of oral .language that willfully includes disparaging and derogatory terms to the residents .or within hearing distance . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact, bed bound, and required extensive assistance from 2 or more people for bed mobility; extensive assistance from 1 person for dressing, eating, and hygiene; was totally dependent with 2 or more people needed for bathing and toileting. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPNs) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the Director of Nursing (DON) on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Observation and interview of Resident #5 on 9/19/17 at 8:55 AM in the resident's room revealed the resident was awake, alert, oriented, on the ventilator and unable to speak out loud. Continued observation revealed the resident was able to nod yes or no and mouthed words when spoken to. Interview with the resident revealed she was able to confirm the facts were the same as written by LPN #5. Interview with LPN #5 on 9/18/17 at 10:30 AM in the conference room revealed, .(Resident #5) was crying and (CNA #6) was cleaning her up and telling her she wasn't catering to her ass .asked her (CNA #6) to leave because she was being aggressive and she said 'F*** this[***] and left .(Resident #5) was still crying and pointed to the door and mouthed 'I don't want her back in my room . Continued interview confirmed the interaction between the resident and CNA #6 was reported immediately to the DON and LPN #5 wrote a statement of the event. Interview with the DON on 9/19/17 at 10:50 AM in the conference room confirmed allegations of verbal abuse to Resident #5 from CNA #6 were substantiated by the facility and CNA #6 was terminated. Continued interview revealed the DON confirmed the facility failed to prevent verbal abuse to Resident #5. Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed Resident #6 was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person required for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed Respiratory Therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 and he said OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and LPN #7 entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Review of handwritten statements in the facility investigation from CNA #5, and CNA #8 dated 7/26/17 corroborated the allegations above. Continued review of LPN #7's written statement revealed, .Resident requested to be 'sent out' .asked what was going on Resident stated, 'I don't feel safe here' .asked why he felt unsafe and who made him feel unsafe .(RT #1) .made him feel uneasy .Resident stated, 'I couldn't breathe and the alarm was going off.' The tech entered the room and resident asked for (RT #1) and he never came. A 2nd tech came and resident requested to see (RT #1) and he finally came. Resident stated, '(RT #1) chewed me out. He told me it was the same people everyday and he wasn't dealing with this crap today.' He turned off the alarm and walked out.' The resident stated, 'I'd rather die than feel the way he makes me feel' . Interview with the RT Director on 9/20/17 at 1:20 PM in the 2nd floor dining room stated she took over RT #1's assignment the morning of 7/26/17. Continued interview revealed the Nurse Practitioner asked her to assess Resident #6's respiratory status as she had heard wheezes in his lungs. Continued interview confirmed the resident had coarse wheezes and the RT Director gave him a PRN (as needed) breathing treatment per the physician's orders [REDACTED].#6 to be believable, she stated, Yes, I do with this situation. Interview with CNA #5 on 9/20/17 at 1:35 PM in the 2nd floor dining room confirmed she had answered the call light of Resident #6 on 7/26/17 between 8:00 AM and 8:30 AM the first time and told RT #1 the resident needed him. Continued review revealed CNA #5 and CNA #8 were working together in another resident's room and CNA #5 was able to confirm CNA #8 answered the resident's call light 2 more times and reported to RT #1 the resident needed him both times. Further interview revealed when the resident's call light went off a 4th time both she and LPN #7 entered the resident's room together and the CNA heard the resident say I want to be moved out, I don't feel safe here. Continued interview revealed LPN #7 asked the resident what was the problem, and the resident said (RT #1) said I'm not dealing with this crap today and turned off my alarms and left. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Interview with the DON on 9/20/17 at 3:36 PM in the conference room revealed RT #1 was terminated. Continued interview confirmed the DON found the written statements dated 7/26/17 by facility staff regarding events occurring to Resident #6 to be truthful. Continued interview confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, and failed to provide care and assistance to Resident #6 as requested resulting in neglect to the resident.",2020-09-01
953,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,226,D,1,0,SMVC11,"> Based on facility policy review and interview, the facility failed to develop a current Abuse Policy containing accurate information related to 2 components, Reporting and Training, of the 7 mandatory requirements maintained in an Abuse Policy, and failed to include and define Exploitation in the facility Abuse Policy. The findings included: Review of facility policy, Abuse Prevention, with an effective date of 11/1/10 and a revised dated of 4/1/17, provided by the Director of Nursing (DON) on 9/18/17 at 9:05 AM revealed, .Any alleged incident of abuse or neglect will be reported immediately to the Administrator .and to other officials in accordance with State Law within 5 working days of the event . Interview with the DON on 9/18/17 at 6:00 PM in the conference room revealed she did not know the 7 components required in the facility Abuse Policy, but would have to check. Continued interview confirmed the DON was the Abuse Coordinator. Further interview revealed the DON and the Social Services Director were responsible for drafting facility policy's with the Administrator signing off on them. Review of facility policy, Abuse, Neglect, Misappropriation Protocol, with an effective date of 1/17/2001 and revised 2/2017 provided by the DON on 9/19/17 at 10:00 AM revealed, .Elder Abuse Act .crime has occurred against a resident .from this facility, he/she MUST notify BOTH .The State Survey Agency (SSA) .A Local Law Enforcement Entity .The facility has identified the .(named city) Police Department to notify if abuse occurs .Reporting of Abuse, Neglect, or Misappropriation/Protection .Reports must be within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion. Within 2 hours (if there is serious bodily injury) .Serious Bodily Injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .All Others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion .Training .All new employees will be trained as part of General Orientation, departmental Orientation, and ongoing training sessions to include .Definition of abuse, neglect, involuntary seclusion and misappropriation of resident property . Continued review of the Abuse, Neglect, Misappropriation Protocol policy revealed the local Police Department identified to notify if abuse occurred was not a local Police Department, not located in the same county as the facility, and was 100 miles away from the facility. Continued review revealed it did not include allegations of abuse in the 2 hour time frame for reporting to the State Agency. Further review revealed the training component did not include annual training for abuse. Further review revealed neither policy included exploitation as a form of resident abuse. Interview with the DON on 9/19/17 at 9:50 AM in the conference room confirmed the Abuse Prevention Policy was not up to date with current federal guidelines for reporting allegations of Abuse within 2 hours. Further interview confirmed the Abuse, Neglect, Misappropriation Protocol did not contain accurate information, and did not accurately reflect the Reporting and Training components required. The DON confirmed the facility failed to maintain an updated Abuse Policy.",2020-09-01
954,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,279,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, review of facility policy,and interview, the facility failed to revise the care plan to reflect the resident's current status for 2 residents (#4, #7) of 11 residents reviewed. The facility failed to update care plans for 2 residents (#4, #7) when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The findings included: Review of the facility's undated policy, Care Plans Comprehensive, revealed: The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of Care Plans: When there has been a significant change in the resident's condition .At least quarterly. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Review of Resident #4's clinical record revealed the resident was readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. Review of a comprehensive assessment, dated 7/10/17, was completed based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. For example, the Care Plan noted the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The Care Plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM. revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed, although the Care Plan identified the resident was at risk for falls, neither of these Physician ordered interventions had been added to the Care Plan. Interview on 9/19/17 at 9:12 AM with Minimum Data Set (MDS) Coordinator #1, in the first floor administrative wing, revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse, in his office revealed it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive care plans) jibes with what's in the closet (where the summary care plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review of Resident #7's revealed [DIAGNOSES REDACTED]. Medical record review of Resident #7's Comprehensive Care Plan with a review date of 9/7/17, revealed the resident was an elopement risk r/t (related to) dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM revealed the resident was seated in a wheelchair in her room. Additional observations on 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair in the third floor dining/day room. No wander alert bracelet was applied to the wheelchair and none was visible on the resident during any of these observations. Interview on 9/19/17 at 8:10 AM with Certified Nursing Assistant (CNA) #1, in the third floor dining/day room, confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1, in the third floor dining/day room, confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1, in his office, revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the care plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly care plan reviews were completed.",2020-09-01
955,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,280,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, and interview, the facility failed to revise the Care Plan to reflect the resident's current status for 3 of 11 sampled residents (#4, #5, #7). The facility failed to update Care Plans for Resident #4 and Resident #7 when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The facility failed to update the Care Plan for Resident #4 to reflect a new intervention for a skin tear. The findings included: Review of facility policy, Care Plans - Comprehensive, undated revealed The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition .At least quarterly. Medical record review revealed Resident #4's clinical record revealed the resident was admitted on [DATE] and readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. A comprehensive assessment dated [DATE], was completed, based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Medical record review revealed the Care Plan noted the resident was at risk for infection r/t (related to) Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed although the Care Plan identified the resident was at risk for falls, neither of these Physician Ordered interventions had been added to the Care Plan. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Interview on 9/19/17 at 9:12 AM with the Minimum Data Set (MDS) Coordinator #1 revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse revealed that it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or Comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive Care Plans) jibes with what's in the closet (where the summary Care Plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Event Report dated 6/18/17 revealed Resident #5 was found with a skin tear to her right inner thigh as a result from scratching herself. Continued review revealed new orders related to the incident was a referral to the Wound Care Nurse. Continued review documented the Care Plan was updated on 6/18/17 at 7:42 PM. Medical record review of the Comprehensive Care Plan dated 2/23/17 revealed a problem of impaired skin integrity. Continued review revealed the approaches were dated 2/23/17 and no new approaches related to the skin tear were present. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the Conference Room confirmed the facility failed to revise Resident #5's Care Plan to reflect approaches related to a skin tear on 6/18/17. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's Comprehensive Care Plan, review date of 9/7/17, revealed the resident was an elopement risk r/t dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM, and 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair. No wander alert bracelet was applied to the wheelchair and none was visible on the resident. Interview on 9/19/17 at 8:10 AM with Certified Nurse Aide (CNA) #1 confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1 confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 with Unit Manager (UM) #1 revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the Care Plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly Care Plan reviews were completed.",2020-09-01
958,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,600,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review and interview the facility failed to ensure 3 (#3, #18, #56) of #35 residents reviewed was free from abuse. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed Resident #56 slapped Resident #3 on 11/3/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dementia without Behavioral Disturbance, Anxiety Disorder and Major [MEDICAL CONDITION]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 99 indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Residents #3 and #56 had a physical altercation. Continued interview revealed Resident #56 smacked Resident #3. Interview with the Director Of Nursing (DON) on 12/11/19 at 3:18 PM in her office revealed she was informed on 11/3/19 of a verbal atercation between Resident #3 and #56. Continued interview revealed she was notified the next day 11/4/19 the altercation between Resident #3 and Resident #56 became physical. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident. Review of facility investigation initiated on 11/2/19 revealed an unwitnessed altercation occurred between Resident #29 and Resident #56. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #29's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating the resident had no cognitive impairment. Continued review revealed the resident exhibited no behaviors. Interview with CNT #1 on 12/9/19 at 2:28 PM in the 3rd floor nurse station revealed Resident #56 was in Resident #29's room; Resident #29 was telling Resident #56 she needed to leave because that wasn't her room. Continued interview she stated I didn't see anything but Resident #29 told me Resident #56 hurt her finger and smacked her arm; I removed Resident #56 and notified the nurse. Interview with Resident #29 on 12/09/19 at 11:34 AM in her room when asked concerning an altercation with her and Resident #56 she stated, I was in my room watching T.V. (television) when the lady came into my room; I asked her to leave the room and she kept coming, she tried going around the corner of my bed so I tried to put my table in front of her to keep her from coming into my room. I kept pushing the table in front of her and she kept kicking my table then she hit me on my right arm. Interview with the DON on 12/11/19 at 3:17 PM in her office revealed she was notified that Resident #56 hit Resident #29 on the arm. Continued interview confirmed Resident #56 hit Resident #29. Review of the facility's investigation dated 11/27/19 revealed an unwitnessed physical altercation between Resident #18 and Resident #26. Further review revealed Resident #26 told the Director of Nursing that she became frustrated because she was trying to watch television when Resident #18 and Resident #3 were arguing; she (named Resident #26) asked them (Resident #3 and #18) to be quiet and they wouldn't be quiet so she slapped Resident #18 on the face. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident had no cognitive impairment. Interview with Resident #26 on 12/9/19 at 3:02 PM in the third floor dining room when asked about the incident between her and Resident #18 she stated, We were kind of fussing last Thursday in the dining room; she didn't want me to sit where I was sitting and cussed me so I slapped her (named resident #18) across the face. Interview with the DON on 12/10/19 at 6:40 PM in her office revealed a physical altercation between Resident #18 and Resident #26 was reported to her on 11/27/19. Continued interview revealed Resident #26 slapped Resident #18 across the face. Review of the facility investigation dated 12/3/19 revealed a physical altercation between Resident #65 and Resident #18 occurred in the dining room witnessed by Resident #58. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Interview with the Resident #65 on 12/9/19 at 2:53 PM in the third floor dining room when asked about an incident between her and Resident #18, she stated (named Resident #18) has a tendency to cuss me and I got mad and just went off and hit her. Interview with CNT #2 on 12/10/19 at 3:35 PM in the third floor nurses station when asked about the altercation between Resident #18 and #65 she stated, I heard (named Resident #18) screaming and I went in the dining room and she was sitting at the table with a cup of coffee and (named Resident #65) had a hold of (named Resident #18) arm. Continued interview revealed she removed Resident #18 and notified her supervisor. Interview with Resident #58 on 12/10/19 at 4:02 PM in the resident's room when asked if she witnessed an altercation between two residents she stated (named Resident #65) can't get along with (named Resident #18); They started arguing and (named Resident #65) went to (named Resident #18) table and started fighting with her (named Resident #18), hitting her. Interview with the DON on 12/10/19 at 6:52 PM in her office revealed the nursing supervisor notified her of a physical altercation between Resident #18 and Resident #65. Continued interview confirmed Resident #65 grabbed Resident #18's arm and Resident #18 hit Resident #65.",2020-09-01
959,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,609,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview the facility failed to report an allegation of abuse timely for Resident #3. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed on 11/3/19 Resident #56 slapped Resident #3. Further review revealed the Director of Nursing (DON) was notified of the incident on 11/4/19. Continued review revealed the DON reported the incident to the state agency on 11/4/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's MDS dated [DATE] revealed the resident had a BIMS score of 99, indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Licensed Practical Nurse (LPN) #2 on 12/11/19 at 10:40 AM on the third floor hallway revealed he didn't witness the altercation between Resident #3 and #56. Continued interview revealed he was unaware of the incident until he was going to clock out and an unnamed tech informed him of a physical altercation between Resident #3 and Resident #56. Continued interview revealed he reported the incident to his supervisor. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Resident #3 and Resident #56 had a physical altercation. Further interview revealed Resident #56 smacked Resident #3. Continued interview revealed CNT #3 reported the incident to her supervisor. Interview with the Director Of Nursing on 12/11/19 at 3:18 PM in her office revealed the staff informed her on 11/4/19 of an altercation between Resident #3 and Resident #56 that occurred on 11/3/19. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident.",2020-09-01
960,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,657,D,0,1,JMLT11,"**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 revise a care plan for 1 (#20) of 35 residents reviewed for care plans. The findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #20's Physician Orders dated 9/29/19 revealed Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine and Pseudomonas in Sputum. Medical record review of Resident #20's comprehensive care plan dated 9/10/19 revealed Resident #20 required isolation related to DX (diagnosis) ESBL in her urine. Continued review revealed no care plan for Isolation related to Pseudomonas in Sputum. Interview with the MDS Coordinator on 12/11/19 at 8:30 PM in the conference room confirmed physician orders were reviewed with MDS updates and care plans were updated according to the orders. Further interview confirmed Resident #20's care plan was not updated for respiratory precautions. She stated I missed it.",2020-09-01
961,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,658,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to follow physician's orders for 2 (#'s 4, #82) residents of 35 residents reviewed for physician orders being followed. The findings include: Facility policy review, Physician Orders, revised (MONTH) 2004, revealed .Physician orders must be given and managed in accordance with applicable laws and regulations .all staff providing care to residents must follow the physician orders . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Physician Order Report dated 7/8/19 revealed .HgbA1C (glycated hemoglobin, a blood test to determine blood sugar levels over a 3 month period) every 3 months . Medical record review of Resident #4's laboratory results revealed there was no HgbA1C obtained for the month of (MONTH) 2019. Interview with the Assistant Director of Nursing on 12/11/19 at 2:50 PM in the conference room confirmed Resident #4 did not have a HgbA1C obtained in (MONTH) 2019. She stated the nurse who put the order in the computer placed the order in the general orders instead of the lab order; so it didn't get done. Interview with the Director of Nursing (DON) on 12/11/19 at 3:18 PM in her office confirmed the HgbA1C was not obtained in (MONTH) 2019 for Resident #4. Medial record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #82's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #82 has a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment, Continued review revealed limb restraint used daily. Medical record review of Resident #82's Physician's Orders dated 6/9/19 revealed .Quarterly Restraint Reduction Assessment once a day every 90 days . Medical record review revealed Resident #82 had no quarterly restraint reduction assessments. Interview with the Director of Nursing (DON) on 12/11/19 at 2:20 PM in her office confirmed no quarterly restraint reduction assessments for Resident #82 had been completed.",2020-09-01
962,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,695,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility procedure review, medical record review, observation and interview, the facility failed to properly store suction tubing prevent the spread of infection for 1 resident (#41) of 48 residents who received respiratory services. The findings include: Facility procedure review, [MEDICAL CONDITION] Suction, undated, and Inline [MEDICAL CONDITION] Suction, undated, revealed .Attach connective tubing to closing cap on lid of canister . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Physician order [REDACTED].Tracheal Suction . Observation on 12/9/19 at 12:43 PM in Resident #41's room revealed suction tubing laying on bedside table, not connected to machine and exposed Interview with Respiratory Therapist #2 on 12/9/19 at 12:43 PM in Resident #41's room confirmed suction tubing was left exposed and not connected to the suction canister. Interview with the Respiratory Director on 12/11/19 at 8:52 AM in the conference room confirmed if there is an open tube it should be covered while not in use and if found uncovered the tubing would be changed.",2020-09-01
963,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,758,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to write a stop date for an as needed [MEDICAL CONDITION] medication for 2 (#33, #56) of 14 residents reviewed for [MEDICAL CONDITION] medications. The findings include: Facility policy review, Antipsychotic Medication Use, dated 3/15/18 revealed .The need to continue PRN (as needed) orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #33's Physician order [REDACTED].[MEDICATION NAME] (an antianxiety medication) tablet 0.25 mg(milligram)1 tab (tablet) gastric tube Three Times A Day - PRN . Medical record review of Resident #33's Pharmacy Communication/Recommendations dated 11/27/19 revealed .[MEDICATION NAME] 0.25mg .PRN [MEDICAL CONDITION] medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Interview with the Director of Nursing (DON) on 12/11/19 at 6:55 PM in her office revealed when asked to review Resident #33's Physician order [REDACTED]. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Physician order [REDACTED].[MEDICATION NAME] (lorazapam) (medication used to treat anxiety) Schedule IV tablet; 0.5 mg; oral Special Instructions: anxiety and tremors every 3 hours-PRN . Medical record review of Resident #56's Pharmacy Communication/Recommendations dated 11/25/19 revealed .[MEDICATION NAME] 0.5 mg .PRN [MEDICAL CONDITION] medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Medical record review of Resident #56's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 12/11/19 at 8:55 AM in her office confirmed there was no stop date for Resident #56's PRN [MEDICATION NAME]. Interview with Resident #33 and #56's Physician on 12/11/19 at 6:45 PM at the second floor nurse station he stated generally don't write stop dates and the resident needs these medications.",2020-09-01
964,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,880,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to post correct signage for droplet isolation precautions for 1 resident (#20) and failed to wear proper personal protective equipment (PPE) before entering the room for 1 (#38) of 14 residents reviewed for transmission based precautions. The findings include: Facility policy review, Isolation, dated (MONTH) 1, 2008 and revised (MONTH) (YEAR) revealed .Signs-Use color coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .In addition to Standard Precautions, Implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #20's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required suctioning and [MEDICAL CONDITION] care. Medical record review of Resident #20's Physician order [REDACTED].Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine Pseudomonas in Sputum . Observation on 12/9/19 at 11:20 AM outside of Resident #20's room revealed signage on the door was for contact isolation and no signage for respiratory isolation. Observation on 12/10/19 at 9:49 AM outside of Resident #20's room revealed Respiratory Signage speak with nurse before entering room .wash hands, mask and gloves . Interview with the Registered Respiratory Therapist (RRT) on 12/09/19 at 11:25 AM revealed resident #20 was in contact and droplet isolation. Further interview confirmed the Droplet Precautions were not posted. Interview with the ADON on 12/11/19 at 4:13 PM in her office confirmed she expected to find the correct isolation signage and PPE's on respective doors per facility policy. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #38's Admission MDS dated [DATE] revealed the resident received suctioning and [MEDICAL CONDITION] care. Medical record review of Resident #38's Physician order [REDACTED].Isolation: Patient on droplet isolation for Pseudomonas Sputum . Observation on 12/11/19 at 8:15 AM outside of Resident #38's room revealed Registered Nurse (RN) #1 entered the resident's room without applying proper PPE. Interview with RN #1 confirmed she did not apply the proper PPE before entering resident #38's room. Interview with the Director of Nursing (DON) on 12/11/19 at 8:15 AM in her office confirmed nursing must apply proper PPE prior to entering isolation rooms at all times.",2020-09-01
967,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,585,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of the facility's Grievance Log, and interview, the facility failed to investigate reported grievances for 2 residents (#40,#57) of 28 sampled residents. The findings include: Review of the facility policy, Filing Grievances/Complaints revised 11/2010 revealed .Any resident .may file a grievance or complaint concerning .behavior of another resident . Review of the facility policy, Investigating Grievances/Complaints revised 11/2010 revealed .Grievances and/or complaints may be submitted orally . Review of facility policy, Grievance/Complaints - Staff Responsibility revised 11/2010, revealed .Should a staff member .be the recipient of a complaint voiced by a resident .concerning .the behavior of another resident .the staff member is encouraged to guide the resident .as to how to file a written complaint with the facility . Review of the facility policy, Grievance/Complaint Log revised 11/2010, revealed .The disposition of all .complaints must be recorded on the Resident Grievance/Complaint Log .The following information, as a minimum, must be recorded: a. The date the .complaint was received .b. The name and room number of the resident filing the .complaint .d. The date the alleged incident took place; e. the name of the person(s) investigating the incident; f. The date the resident .was informed of the findings; and g. The disposition of the grievance (i.e., resolved, dispute, etc.) . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #40's annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Interview with Resident #40 on 1/14/19 at 11:11 AM, in the resident's room, confirmed she had mentioned an incident at the facility involving another resident to several staff, including the Activities Assistant. Interview with the Activities Director on 1/16/19 at 8:07 AM, in the activities room, confirmed she was aware of the alleged incident of another resident yelling at Resident #40. Further interview confirmed We don't have any documentation for that (the investigation) . Medical record review revealed Resident #57 was admitted on the facility on 8/6/18 with [DIAGNOSES REDACTED]. Medical record review of Resident #57's annual MDS dated [DATE] revealed Resident #57 had a BIMS of 15, indicating the resident was cognitively intact. Interview with Resident #57 on 1/15/19 at 1:30 PM, in the activities room revealed a large bottle of body spray had gone missing from her personal belongings in her room. Continued interview revealed Resident #57 had reported the missing item to the Social Services Director. Review of the facility monthly Grievance Log dated 1/2018 through 12/2018, revealed the facility failed to document Resident #57's missing body spray. Further review revealed the facility failed to document the alleged incident of another resident yelling at Resident #40. Interview with the Social Services Director (SSD) and the Director of Nursing (DON) on 1/15/19 at 2:24 PM, in the social services office, confirmed the missing body spray was verbally brought to the attention of the SSD during the summer and the missing item had not been recorded on the Grievance Log. Further interview confirmed no investigation was conducted and the steps of the grievance policies were not followed. Interview with the DON on 1/16/19 at 9:27 AM, in the Admission's office, confirmed Resident #40 was not encouraged to file a written complaint with the facility and the incident was not recorded on the Grievance Log. Further interview confirmed .We do not have documentation or (an) investigation into this incident. I did not feel we needed to investigate into this incident . Continued interview confirmed the facility failed to follow their policies.",2020-09-01
968,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,679,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to revise an ongoing activity program and provide activities for 1 resident (#37) of 3 residents reviewed for activities of 28 sampled residents. The findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Activities Evaluation dated 3/29/16 revealed the resident's preferences included animals/pets, movies, music, radio, reading, religious services, religious studies, and television. Medical record review of Resident #37's Record of One to One Activities dated 5/3/18 to 8/31/18 revealed the resident .prefers not to participate in group activities .frequency of one to one activity .2 times a week . Further review revealed the staff watched television with the resident and read stories to her. Continued review revealed the time spent with the resident on the one to one activities was between 5 to 10 minutes. Further review revealed one to one activity had been documented for Resident #37 after 8/31/18. Medical record review of the Care Plan Conference Summary dated 9/6/18 revealed .Activities 1 on 1 in room . Further review revealed the resident's Power of Attorney (POA) agreed with the plan of care established. Medical record review of the Interdisciplinary Progress Notes dated 9/6/18 revealed .Quarterly Act (activity) Rec (recreational): Pt (patient) continues to receive 1:1 services. Pt. enjoys having a book read to her. Pt. continues to be confused. Will continue to encourage leisure participation and provide recreational opportunities . Medical record review of the Therapeutic Recreation Care Plan implemented on 9/9/18 revealed the Resident #37 was independent for activities, cognitive stimulation and social interaction. Continued review revealed the resident had physical limitations and cognitive deficits. Further review revealed the interventions were as follows: celebrations/parties, 1:1 visits, and small group activities. Medical record review of the Interdisciplinary Progress Notes dated 12/3/18 revealed .Annual Act/Rec: Pt. continues to receive 1:1 services 2 x (times) per week. Staff completed assessment. Pt. enjoys listening to music and listening to a book read to her. Pt. continues to be confused. Will continue to encourage leisure participation and provide recreational opportunities . Observation of the resident on multiple occasions from 1/14/19 at 10:30 AM until 1/16/19 at 11:00 AM during hours of survey revealed the resident lying in the bed, with no activity except the television set turned on being provided. Interview with the Activity Director on 1/15/19 at 2:00 PM, in the conference room, revealed the 1:1 in room activities were stopped in (MONTH) due to they felt the resident .did not benefit from 1:1 in room activities . She stated, a service animal did come to the facility every 2 weeks and the resident acknowledged the animal, however documentation of this activity was not completed. Telephone interview with the resident's POA on 1/15/19 at 2:10 PM revealed he thought they were reading to her and providing 1:1 in room activities. Further interview revealed the resident liked romance novels, blue grass music and animals. Continued interview revealed he would like anything that they could do for her that would occupy her time. Further interview revealed reading to her helps to occupy her mind and he was not informed the 1:1 activities had been discontinued. Interview with the Activity Director on 1/15/19 at 4:15 PM, in the activities room, confirmed the resident's Activity Program had not been revised to include current interests and available activities, and the resident had not received in room activities since (MONTH) (YEAR).",2020-09-01
969,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,757,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure each resident was free of unnecessary drugs by failing to adequately monitor residents receiving psychoactive medications for 6 residents (#33, #36, #37, #39, #41, and #56) of 28 sampled residents. The findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #33's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15, indicating the resident was cognitively intact. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #33 received anti-psychotics, anti-anxiety, and anti-depressant medications during the 7 day look back period. Medical record review of Resident #33's care plan dated 8/28/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident experienced delusions and no mood/behavior in the 7 day look back period. Further review revealed Resident #36 received anti-anxiety and anti-depressant medications during the 7 day look back period. Medical record review of Resident #36's care plan dated 9/6/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #37 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #37's quarterly MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed Resident #37 experienced delusions and had no mood/behavior during the 7 day look back period. Further review revealed the resident received anti-anxiety and anti-depressant medications during the 7 day look back period. Medical record review of Resident #37's care plan implemented 12/3/18 revealed the use of psychoactive with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. Continued review revealed no mood/behavior during the 7 day look back period. Further review revealed Resident #39 received anti-psychotic and anti-depressant medications during the 7 day look back period. Medical record review of Resident #39's care plan dated 6/27/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #41 received anti-depressant medications during the 7 day look back period. Medical record review of Resident #41's care plan dated 9/19/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #56 was admitted to facility on 7/31/18 with [DIAGNOSES REDACTED]. Medical record review of Resident #56's admission MDS dated [DATE] revealed the resident's BIMS was 5, indicating severe cognitive impairment. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #56 received anti-depressant medications during the 7 day look back period. Medical record review of Resident #56's care plan dated 4/23/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Review of the Behavior/Intervention Monthly Flow Records for 11/1/18 through 1/16/19 revealed incomplete documentation for Residents #33, #36, #37, #39, #41, and #56. Interview with the Director of Nursing on 1/16/18 at 2:45 PM, in the Admission Office, confirmed behavior monitoring had not been done consistently from 11/1/18 - 1/16/19 for Residents #33, #36, #37, #39, #41, and #56.",2020-09-01
971,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,880,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to maintain acceptable infection control practices during the ice/water pass on 1 of 2 hallways observed of 5 hallways total; during food tray delivery on 1 of 5 hallways observed of 5 hallways total; and during medication administration of 1 of 2 medication carts observed of 3 medication carts total. The findings include: Review of the facility policy, Serving Drinking Water, revised 10/ 2010, revealed .take the water pitcher to the ice cart outside the room. Fill the pitcher with ice .return the water pitcher to the resident's bedside stand .Wash your hands . Review of the facility policy, Handwashing/Hand Hygiene, revised 8/2015 revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Use an alcohol-based hand rub .or .soap (antimicrobial or non-antimicrobial) and water for the following .After contact with objects .before handling food . Observation on 1/14/19 at 11:07 AM, on the unit 2 hallway, revealed Certified Nursing Assistant (CNA) #1 passing ice. Further observation revealed CNA #1 entered a resident room, retrieved a water pitcher, came out into the hallway, and filled the water pitcher with ice. Continued observation revealed CNA #1 re-entered the room, placed the water pitcher on the bedside table, and exited the room without sanitizing the hands. Further observation revealed CNA #1 entered a different resident room, retrieved a water pitcher, came out into the hallway, and filled the water pitcher with ice. Continued observation revealed CNA #1 re-entered the room, placed the water pitcher on the bedside table, and exited the room without sanitizing the hands. Interview with CNA #1 on 1/14/19 at 11:12 AM, on the unit 2 hallway, confirmed she had failed to sanitize her hands before exiting the resident's room after filling up the water pitcher and placing it on the bedside table. Further interview confirmed she entered another resident room, filled up the water pitcher, placed it on the bedside table, and exited the room without sanitizing the hands. Observation on 1/14/19 at 12:26 PM, on the H hall, revealed CNA #2 entered room [ROOM NUMBER] with a meal tray, and set the tray down. Continued observation revealed CNA #2 touched the resident's wheelchair (w/c) handles, touched the light switch, and touched the tray table. Further observation revealed CNA #2 then set up the resident's tray without washing her hands. Interview with CNA #2 on 1/14/19 at 12:29 PM, on the H hall, confirmed CNA #2 had entered room [ROOM NUMBER] with a meal tray and set the tray down. Continued interview confirmed CNA #2 touched the resident's w/c handles, the light switch, the tray table, and exited the resident's room without washing her hands. Interview with the Director of Nursing (DON) on 1/15/19 at 8:53 AM, in her office, revealed CNA #1 had failed to follow the facility's infection control policy for passing ice. Interview with the DON on 1/15/19 at 3:27 PM, in the conference room, confirmed the facility failed to follow the Handwashing/Hand Hygiene policy. Observation on 1/15/19 at 8:10 AM, at the East Wing cart 1 medication cart, revealed Licensed Practical Nurse (LPN) #1 was preparing medication for Resident #44. Further observation revealed LPN #1 dropped 2 pills on top of the medication cart, picked the pills up with her bare hands, and placed the medication in a small plastic cup. Continued observation revealed LPN #1 entered Resident #44's room and administered the medications. Interview with LPN #1 on 1/15/19 at 8:30 AM, in the East Wing hallway, at #1 medication cart, confirmed she had failed to follow infection control practices during medication administration by touching the medication with her bare hands. Interview with the DON on 1/15/19 at 8:53 AM, in her office, confirmed LPN #1 failed to follow the infection control policy during medication administration.",2020-09-01
972,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,550,D,0,1,4NS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure clothing promoted dignity for one resident (#29) and failed to achieve a dignified appearance for one resident (#17) of 20 residents reviewed. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) annual assessment dated [DATE], revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 2, indicating the resident was severely cognitively impaired. Medical record review of a care plan dated 9/11/17 revealed .unable to dress .the resident will receive appropriate staff support with .dressing . Observation of Resident #29 on 2/4/18 at 11:58 AM, on the 200 hall outside of the resident's room, revealed Resident #29 sitting in a wheel chair wearing a shirt that was stretched out around the neck and pulled down in the front exposing her chest. Observation of Resident #29 on 2/5/18 at 3:37 PM, on the 200 hall outside of the resident's room, revealed the resident was sitting in a wheel chair wearing the same shirt she had on the day before, and it was pulled down in the front exposing her chest area. Interview with Certified Nurse Assistant (CNA) #2 on 2/05/18 at 4:05 PM, at the 200 hall nurse's station, confirmed .no it's not okay for her to have on a shirt that is exposing her chest area .I did see her in that shirt yesterday also . Interview with the Director of Nursing (DON) on 02/05/18 at 4:16 PM, confirmed Resident #29 was not wearing clothing to promote dignity. Medical record review revealed Resident #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE], revealed the resident was totally dependent for bed mobility, transfers, dressing, toilet use, and personal hygiene. Observations on 2/4/18 at 11:25 AM, 2/5/18 at 2:40 PM, and 2/5/18 at 2:50 PM, revealed Resident #17 had a large amount of facial hair on her chin. Interview during observation on 2/5/18 at 2:40 PM, revealed she did not like the facial hair on her chin. Continued interview with the resident revealed the facility had not removed it since she had been admitted and she would like the hair removed. Interview with the Social Services Director on 2/5/18 at 2:50 PM, in the resident's room, confirmed the resident had facial hair on her chin. Continued interview confirmed the resident should be able to have the facial hair removed if desired.",2020-09-01
973,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,689,D,0,1,4NS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement interventions to prevent falls for 1 resident (#5) of 4 residents reviewed for falls. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required maximum assistance of 2 staff for transfers, was able to propel self in her wheel chair with supervision, and was non-ambulatory. Medical record review of an Incident/Accident Report dated 1/28/18 revealed Resident #5 was seated in her wheel chair with staff pushing the chair, and the resident .tumbled forward onto knees and then scraped forehead on floor. Causing abrasion/carpet burn to forehead . Medical record review of the Incident/Accident Report dated 1/29/18 revealed Resident #5 was seated in her wheel chair in her room and .Attempted to get out of chair and slid out of chair onto floor, hitting outer left eye on floor causing a purple knot .Steps taken to prevent recurrence .(non-skid surface) to w/c . Medical record review of Resident #5's care plan revised on 1/29/18 revealed non-skid surface to w/c . Observation on 2/5/18 at 7:30 AM, 9:30 AM, 1:15 PM, 2:30 PM, 3:00 PM, 3:30 PM, in various places, revealed Resident #5 sitting in her wheelchair without the non-skid surface in the seat to prevent sliding out of the wheel chair. Continued observation revealed the resident's face was brown/blue/purple around the forehead and eyes. Observation and interview with the Director of Nursing (DON) and Certified Nurse Assistant (CNA) #3 on 2/5/18, at 3:50 PM in the main hallway near the kitchen, revealed CNA #3 and the DON assisted Resident #5 to stand from the wheel chair. Continued observation revealed the non-skid surface was not present in the seat to prevent Resident #5 from sliding out of the wheel chair. Interview with the DON confirmed the intervention to prevent further falls was to have non-skid surface in the resident's wheel chair and the non-skid surface was not present.",2020-09-01
974,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,761,D,0,1,4NS111,"Based on review of facility policy, observation, and interview, the facility failed to assure medications were secure and inaccessible for one resident (#68) of 82 residents observed. The findings included: Review of the facility's policy, Storage of Medications revised (MONTH) 2007, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation on 2/4/18 at 11:30 AM, in Resident #68's room, revealed a bottle of antacid on the resident's bedside table. Interview with Licensed Practical Nurse #5 on 2/4/18 at 11:35 AM, at the unit 2 nurse's desk, confirmed medications were not to be at the bedside. Interview with the Director of Nursing on 2/5/18 at 9:30 AM, in the hallway near the activity room, confirmed medications were not to be at the bedside.",2020-09-01
975,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,880,D,0,1,4NS111,"Based on facility policy, observation, and interview, the facility failed to follow the facility's policy for hand hygiene during medication administration for one resident (#62) of 8 residents observed; and failed to follow infection control practices during a wound dressing change for one resident (#52), of two residents reviewed for infection control, of 20 sampled residents. The findings included: Review of the facility's policy Instillation of eye drops revised (MONTH) 2014, revealed . 2. Wash and dry your hands thoroughly. 3. Put on gloves . Review of the facility's policy, Wound Care, revised date (MONTH) 2010, revealed .Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam gloves Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .21. Wipe reusable supplies with alcohol as indicated (i.e. outside of containers that were touched by unclean hands, scissor blades, etc.) Return reusable supplies to resident's drawer in treatment cart. 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. 23. Wash and dry your hands thoroughly . Observation of Registered Nurse (RN) #1 during medication administration on 2/5/18 at 8:14 AM in Resident #62's room, revealed RN #1 failed to wash his hands and apply gloves prior to administering eye drops. Interview with RN #1 on 2/5/18 at 8:18 AM, in the unit two hallway, confirmed hands were to be washed and gloves applied prior to administering eye drops. Interview with the Director of Nursing (DON) on 2/5/18 at 9:30 AM, in the hallway near the activity room, confirmed it was the facility's policy to wash hands and put on gloves prior to administering eye drops. Observation of a dressing change for Resident #52 on 2/4/18, at 10:25 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #3 was preparing to perform a dressing change on 3 wounds on the resident's right foot. Continued observation revealed the following: 1. Gathered supplies in a large see-through plastic bag. The large plastic bag was placed on the bedside table with no barrier. 2. Donned gloves, removed old dressing. 3. Retrieved clean supplies from the large plastic bag with the same gloves. 4. Opened the supplies, laid the supplies and scissors on the resident's bed. (No barrier). 5. Cleaned wound, with the same gloves, and retrieved additional supplies from the plastic bag. (The LPN had a scarf around her neck, observation revealed each time she bent to do anything to the resident's wounds, the scarf was touching bed, and resident's linen.) 6. Applied an ointment on the wound with applicator using the same gloves. 7. Picked up supplies and scissors from the resident's bed and placed them on the bedside table. 8. Removed the gloves, washed hands, exited the room, returned with additional supplies and placed supplies on bedside table. 9. Donned gloves, opened gauze packages, placed gauze on the resident's wounds, wrapped gauze around the entire foot, taped and dated dressing. 10. Removed the gloves, gathered the unused supplies and scissors, placed them in the plastic bag, disposed of garbage. Exited the resident's room, without disinfecting hands, took the plastic bag of supplies to the supply room, and disinfected hands after entering the room. Interview with the Infection Control Nurse on 2/6/18 at 8:00 AM, in the dining area, confirmed the facility had failed to follow infection control practices during the dressing change. Continued interview confirmed the gloves were to be changed after removing the old dressing, barriers were to be placed, scissors were to be disinfected after use, and only the supplies needed for the resident were to be taken in the room. The Infection Control Nurse confirmed the LPN #3 was not to wear a scarf during the dressing change due to possible cross-contamination. Interview with the DON on 2/6/18 at 8:20 AM, in the dining area, confirmed the facility had failed to follow infection control practices during the dressing change and failed to follow policy.",2020-09-01
977,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,558,D,0,1,HJSI11,"**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 provide water and ice at the bedside for 1 resident (Resident #6) of 14 residents reviewed. The findings include: Review of the facility policy titled, Safe Distribution of Water and Ice, undated, showed .Pass fresh ice water to residents three times daily, approximately every eight hours and prn (as needed). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact. During observation and interview on [DATE] at 11:35 AM, in the resident's room, Resident #6 stated the facility did not regularly fill up the water pitchers. The resident had 2 water pitchers in the room and both pitchers were empty. Observation on [DATE] at 9:07 AM, in the resident's room, showed 2 water pitchers in the room and both pitchers were empty. During an interview on [DATE] at 3:09 PM, Registered Nurse (RN) #1 confirmed Resident #6 preferred to have 2 water pitchers. The resident preferred one water pitcher to have ice in it to pour soda over and the other water pitcher to have ice and water. During interview and observation on [DATE] at 3:34 PM, Resident #6 confirmed she wanted water and ice in one water pitcher, and only ice in the other pitcher, so she could pour soda in it. One water pitcher had ice with a small amount of water and the other water pitcher was empty. During an interview on [DATE] at 5:26 PM, the Director of Nursing confirmed it was her expectation for ice and water to be passed every shift to the residents.",2020-09-01
978,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,569,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's Trust Statement Report, and interview, the facility failed to refund personal funds within 30 days of discharge for 1 resident (Resident #247) of 28 residents reviewed. The findings include: Resident #247 was admitted to the facility on [DATE] and discharged home on[DATE]. Review of the facility's Trust Statement dated 12/31/2019 showed Resident #247 had $2,478.00 remaining in the trust fund. During an interview conducted on 2/25/2020 at 9:40 AM, the Administrator and Social Service Director confirmed the facility failed to refund personal funds within 30 days from discharge for Resident #247. During an interview conducted on 2/25/2020 at 9:50 AM, the Business Office Manager confirmed Resident #247 was discharged on [DATE] with a remaining balance of $2,478.00 in his trust fund.",2020-09-01
979,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,580,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the physician an orthopedic consult was not obtained as ordered for 1 resident (Resident #10) of 28 residents reviewed. The findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed Resident #10 was cognitively intact, able to walk independently without assistive devices, and had not had any falls. Review of a Situation Background Assessment and Recommendation (SBAR) Communication Form and progress note dated 10/21/2019, for Resident #10 showed .slip/fall to knees .resident was walking down the hall when she slipped and landed on her knees. mainly on her right knee. denies pain at this time . Medical record review of nurse's notes and x-ray results revealed Resident #10 began to experience swelling and pain on 10/30/2019 and the facility obtained an x-ray on 10/30/2019 that showed the resident had a right knee fracture. Review of a nurse's note dated 10/30/2019 at 3:55 PM showed .Residents' radiology report back .Acute right knee fracture .(Nurse Practitioner #1) .instructed staff to instruct resident to stay off knee, Therapy needs to get resident something to immobilize her knee .get resident an appointment with a orthopedic as soon as possible . Review of a nurse's note dated 10/31/2019 showed .Unit manager received a order for resident (#10) to go to emergency room for eval (evaluation) of fracture to her right patella .returned to facility at 1:10 PM. She is wearing a full brace to RLL (right lower leg) .Already has order for consult with ortho (orthopedic) . Review of the emergency room visit summary dated 10/31/2019, showed Resident #10 was to follow up with the orthopedic clinic in 2 days related to a closed [MEDICAL CONDITION] patella. Review of nurse's notes dated 11/1/2019 - 11/15/2019 showed Resident #10 was ambulating without the right knee brace. Review of a nurse's note dated 11/10/2019 showed .Resident (#10) ambulatory .(orthopedic clinic) contacted re (regarding) Consult r/t (related to) fracture; stated she can come into Walk in Clinic. Will Schedule transportation . Review of the medical record and nurse's notes showed no documentation Resident #10 was seen at the orthopedic clinic for consult of the right patellar fracture 2 days after the emergency room visit, as ordered, or after the call to the orthopedic clinic on 11/10/2019. The medical record showed no documentation the physician was notified of the missed orthopedic consult appointment. Observation on 2/23/2019 at 11:05 AM and 12:33 PM, showed Resident #10 ambulating in her room and in the hall without a right knee brace. During an interview on 2/24/2020 at 7:45 AM, Licensed Practical Nurse (LPN) #1 stated she was aware Resident #10 had a physician's orders [REDACTED]. LPN #1 stated she was not aware if the resident went to the consultation appointment and was not able to find documentation the resident had the consultation. LPN #1 confirmed she had not notified the Nurse Practitioner (NP) or the Physician of the missed orthopedic appointment for Resident #10. Telephone interview with Resident #10's orthopedic clinic on 2/26/2020 at 8:55 AM, confirmed the resident had not been seen by the clinic for consultation of the right knee fracture. During telephone interview on 2/26/2020 at 9:35 AM, the facility Nurse Practitioner (NP #1) was not aware the resident had not been seen by the orthopedic clinic and had not been notified of the missed appointment.",2020-09-01
980,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,584,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation, and interview, the facility failed to maintain resident wheelchairs in good repair for 2 residents (Residents #17 and #27) of 28 sampled residents. The findings include: Review of the facility policy titled, Maintenance Service, revised December 2009, showed .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #17 had severe cognitive impairment and used a wheelchair for mobility. During observation and interview on [DATE] at 12:36 PM, LPN #3 stated the wheelchair Resident #17 was seated in belonged to the facility and confirmed the back rest of the wheelchair was torn approximately 1 inch on each side beside the handles. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident #27's room on [DATE] at 11:00 AM showed a wheelchair cushion in the resident's reclining wheelchair had cracks in the cover of the cushion and cracks on the right side of the headrest cover. During an interview on [DATE] at 11:40 AM, the Director of Nursing (DON) confirmed the right headrest and cushion to Resident #27's wheelchair was cracked. During an interview on [DATE] at 12:44 PM, the Director of Rehab stated the staff should report any tears to the wheelchairs to him so the chair could be replaced. During an interview on [DATE] at 4:10 PM, the Director of Rehab confirmed the cushion to Resident #27's wheelchair was cracked and should be replaced. During an interview on 2/26/2020 at 7:42 AM, the Director of Nursing (DON) confirmed it was her expectation that wheelchairs with tears would be reported so the items could be repaired or replaced.",2020-09-01
981,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,684,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain a physician's order for hospice services for 1 resident (Resident #34) of 5 residents reviewed for hospice. The findings include: Resident #34 was admitted from an acute care hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Hospice Coordinated Plan of Care showed the first visit and the plan of care was initiated at the facility on 10/23/2019. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #34 received hospice services. Review of the care plan revised 1/23/2020, showed Resident #34 had a terminal prognosis related to [MEDICAL CONDITION] with the interventions of working cooperatively with the hospice team to provide for the resident's spiritual, emotional, physical and social needs. Review of the medical record showed no documentation of a physician's order to admit to or to continue hospice services for Resident #34. Review of the current Physician's orders dated 2/4/2020 showed no order for hospice services. During an interview on 2/26/2020 at 1:00 PM, the Director of Nursing (DON) stated Resident #34 received hospice services at home prior to admittance to the facility. The DON stated the Medical Director for the hospice service and the facility's Medical Director were the same physician and did not feel a new order was necessary. The DON confirmed the facility did not obtain a new order to admit to hospice services or to continue hospice services upon Resident #34's admission to the facility.",2020-09-01
984,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,692,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to document the amount of a nutritional supplement consumed and failed to discuss artificial nutrition (feeding tube in the stomach to infuse liquid nutrition) after an unavoidable weight loss for 1 resident (Resident #19); and failed to implement dietitian recommendations to increase the rate of enteral nutrition (tube feeding) for 1 resident who had a significant weight loss (Resident #44) of 5 residents reviewed for nutrition. The findings include: Review of the facility policy titled, Weight Assessment and Intervention, Revised 9/2018, showed .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the .Resident's target weight range .The relationship between current medical condition or clinical situation and recent fluctuations in weight .Whether and to what extent weight stabilization or improvement can be anticipated .Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choice and preferences .The use of supplementation and/or feeding tubes .End of life decisions and advance directives . Review of the facility policy titled, Diet Orders and RDN (Registered Dietitian Nutritionist) Order Writing, dated (YEAR) showed .Diet orders will be written by the physician or .a qualified dietician .The physician will delegate order-writing to a qualified dietician or other clinically qualified nutrition care professional who is acting within the scope of practice as defined by state law . Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's Order for Scope of Treatment (POST) form dated 2/15/2018 showed Resident #19's wished included artificial nutrition to be administered for long term. Review of Resident #19's weight record showed the resident weighed 115 pounds on 9/11/2019. The resident refused to be weighed in October. Review of a Speech Therapy Plan of Care dated 11/19/2019, showed .Staff reports resident with poor PO (by mouth) intake resulting in steady weight loss. Pt. (patient) is unable to maintain adequate hydration and nutrition .IMPRESSIONS .Patient presents with mild oral phase dysphagia (difficulty swallowing) d/t (due to) poor dentition impacting ability to bite and masticate certain textures/food items .Cognitive impairments may contribute to pre-oral phase deficits impacting patient's reasoning & (and) judgement ability and acceptance of PO intake in order to maintain adequate hydration and nutrition . Review of a Diet Order Communication dated 11/22/2019 revealed the resident was on a regular diet with whole milk for breakfast; Mighty Shake (nutritional supplement) for breakfast, lunch and dinner; and Magic Cup (nutritional supplement) for lunch and dinner. Review of Resident #19's weight record showed the resident weighed 97 pounds on 11/30/2019. Review of a Diet Order Communication form by the Speech Language Pathologist (SLP) dated 12/2/2019 showed Resident #19 had chewing and swallowing problems and the diet was changed to pureed with soup added for lunch and supper. Review of the Physician's Order Summary Report showed an order with a start date of 12/11/2019 for the addition of a nutritional supplement, MedPass 120 milliliters (ml) 4 times a day, and to record the amount consumed. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed Resident #19 had severe cognitive impairment. The resident required extensive assistance of 1 person for eating. The resident weighed 97 pounds and had non-prescribed weight loss. Review of Resident #19's weight record showed the resident weighed 97 pounds on 12/30/2019. Review of a Registered Dietitian note dated 12/30/2019 showed Resident #19 had a 10% weight loss in 90 days, but had a stable weight for 30 days. The resident was to continue receiving MedPass 120 ml 4 times daily, Magic Cup twice daily, and Fortified Foods. Review of the Medication Administration Record (MAR) for (MONTH) 2019 revealed the MedPass was administered to the resident, but no documentation of the amount consumed. Review of the care plan revised 1/1/2020, showed Resident #19 had Activities of Daily Living (ADL) self-care performance deficit with interventions including assistance of 1 staff for eating and had an .unplanned/unexpected weight loss r/t (related to) Poor food intake and cognitive deficits impacting pre-oral phase of swallowing .Dysphagia .Monitor and record food intake . The resident had an Advance Directives POST and .Advance Directive will be followed as needed . Review of Resident #19's weight record showed the resident weighed 98.6 pounds on 1/28/2020. Review of the MAR for 1/2020 showed an order for [REDACTED]. The MedPass was documented as given 4 times a day, but there was no documentation of the amount consumed. Review of the Nutrition Report showed the resident had an average meal intake of 41% for the week of 1/31/2020, 43% for the week of 2/7/2020, 46% for the week of 2/14/2020, and 50% for the week of 2/21/2020. Review of the MAR for 2/2020 showed an order for [REDACTED]. The MedPass was documented as given 4 times a day, but there was no documentation of the amount consumed. Review of Resident #19's weight record showed the resident weighed 93.6 pounds on 2/12/2020. Review of a dietary note dated 2/13/2020 showed .Weight Variance with appropriate diet order and nutritional interventions in place, increased MedPass 240 ml TID (three times daily) . Review of a Verbal Physician's Order dated 2/14/2020 showed MedPass 120 ml 4 times per day was discontinued and the MedPass was increased to 240 ml 3 times daily, with instructions to document the amount consumed. Review of the MAR for 2/2020 showed an order for [REDACTED]. The MedPass was documented as given 3 times a day, but there was no documentation of the amount consumed. Review of a Nurse Practitioner Progress Note dated 2/20/2020 showed .ACTIVE PROBLEMS .Weight Loss .social worker is asking if patient is hospice appropriate .her weight has gone down. she is at 93.6 (pounds) .Systemic symptoms weight loss . Appetite poor .Not well nourished .would recommend hospice care, related to advanced dementia, progression of disease, and weight loss .social services will talk to family about conditions and hospice recommendations . Observation on 2/24/2020 at 8:15 AM showed Resident #19 consumed 25% of breakfast and drank 100% of a Mighty Shake. During an interview on 2/24/2020 at 3:45 PM, the Registered Dietitian stated Resident #19's weight had remained stable and then the resident's weight decreased to 93.6 pounds on 2/12/2020. The MedPass was then increased to 240 ml 3 times a day. The RD confirmed she had not seen documentation of the specific amount of MedPass consumed and did not know how much of the MedPass the resident consumed at each administration. The RD reviewed the resident's record and stated she did not know when the Mighty Shake and Magic Cup were ordered and she did not see documentation of when they were ordered. During an interview on 2/24/2020 at 4:50 PM, Licensed Practical Nurse (LPN) #5 stated the resident only consumed 2 ounces (60 ml) of the MedPass at each administration and the resident did not like the taste of the MedPass. LPN #5 stated she did not document the amount of MedPass that was consumed on the MAR because there was not a place to document it on the facility's MAR. Observation on 2/25/2020 at 8:30 AM showed Resident #19 consumed 75% of breakfast, and 100% of a Mighty Shake. During interview on 2/25/2020 at 8:35 AM, Certified Nursing Assistant (CNA) #1 stated the MedPass amounts were documented in the computer. I think you can put a percentage or amount in there. CNA #1 was unable to provide the documentation on the amount of the MedPass consumed by Resident #19. During an interview on 2/25/2020 at 10:30 AM, the RD stated she was not aware of Resident #19's wishes on the POST form for a feeding tube. The RD stated she was not aware of the amount of MedPass consumed by Resident #10. The RD was not aware the amount of MedPass had not been documented on the MAR. The RD was not aware Resident #19 preferred the mighty shake over the MedPass. The RD stated the facility staff had not advised her Resident #10 had not consumed the ordered amount of the MedPass. During telephone interview on 2/25/2020 at 11:00 AM, Resident #19's family member stated he was aware the resident had declined and had weight loss. The family member reported the facility had not discussed the option of a feeding tube with him but he did want to discuss the pros and cons with the facility staff. During an interview on 2/25/2020 at 1:32 PM, the Director of Nursing (DON) confirmed the percentage of MedPass had not been documented on the 1/2020 and 2/2020 MARs. During observation on 2/26/2020 at 7:40 AM, Resident #19 consumed 50% of breakfast and drank 100% of the Mighty Shake. During telephone interview on 2/26/2020 at 9:33 AM, the Nurse Practitioner (NP #1) stated she was aware of the resident's weight loss and had recently recommended hospice services. NP #1 was not aware the resident's POST form indicated a desire for artificial nutrition. NP #1 stated when the facility recognized the significant weight loss, the facility staff should have communicated with the family and discussed the resident's wishes. NP #1 stated she had not spoken with the family regarding a feeding tube. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 11/24/2019 showed Resident #44 required a feeding tube with interventions including .RD to evaluate quarterly and PRN (as needed) .Make recommendations for changes to tube feeding as needed . Review of the quarterly MDS dated [DATE] showed Resident #44 had severe cognitive impairment, had a feeding tube, and had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months (significant weight loss). Review of a dietary progress note dated 2/14/2020 showed .spoke with nursing and resident tolerating rate and formula .increasing rate to 65 ml (milliliter)/24 hour . Observation on 2/23/2020 at 10:55 AM, in Resident #44's room, showed a feeding pump infusing tube feeding formula at 55 ml/hour. During an interview on 2/24/2020 at 1:20 PM, LPN #3 stated there was a physician's order for Resident #44's tube feeding to infuse at 55 ml/hour. During observation and interview on 2/24/2020 at 2:55 PM, the RD confirmed the tube feeding was infusing at 55 ml/hour. The RD stated on 2/14/2020 she discussed the recommendation of increasing the enteral feeding from 55 ml/hour to 65 ml/hour with LPN #4 and was told LPN #4 .would take care of it . Review of a Medication Administration Record dated 2/1/2020-2/29/2020 and the Order Summary Report showed the tube feeding was increased to 65 ml/hr on 2/24/2020.",2020-09-01
985,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,695,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to properly store a nebulizer mask and tubing in a sanitary manner for 1 resident (Resident #38) of 6 residents reviewed receiving respiratory care. The findings include: Review of the facility policy titled, Department (Oxygen Respiratory Therapy) - Prevention of Infection, dated 10/1/2018, showed .To provide a guide to prevention of infection associated with oxygen respiratory therapy tasks and equipment .Keep the oxygen cannula .in a plastic bag when not in use . Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #38 received oxygen therapy. Review of the care plan revised 2/21/2020 showed Resident #38 had a respiratory infection with an intervention of [MEDICATION NAME][MEDICATION NAME] (medication to open airways) via nebulizer (aerosol treatment machine) as ordered by the physician. Review of the Physician's order dated 2/21/2020, showed .[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) Solution .inhale orally four times a day for dyspnea (difficulty breathing/shortness of breath) . Observation on 2/23/2020 at 11:13 AM, showed Resident #38 had a nebulizer treatment machine with the treatment tubing and mask lying in the chair beside the resident's bed, uncovered, and not stored in a bag. During an interview conducted on 2/23/2020 at 11:20 AM, in Resident #38's room, Licensed Practical Nurse #2 confirmed the nebulizer mask was not stored in a plastic bag. During an interview with the Director of Nursing (DON) on 2/23/2020 at 3:31 PM, the DON confirmed it was her expectation for nebulizer tubing and masks to be stored in a plastic bag when not in use.",2020-09-01
987,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,758,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a PRN (as needed) anti-anxiety medication was not used beyond 14 days without a rationale and without documentation of duration for 2 Residents (Residents #26 and #29) of 5 residents reviewed for unnecessary medications. The findings include: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #26 had moderate cognitive impairment, delusional behaviors, and received antipsychotic and antidepressant medications for 7 days of the past 7 days. Review of a physician's orders [REDACTED]. Review of a Consultant Pharmacist Communication to the Physician dated 2/14/2020 (almost 1 month after the last [MEDICATION NAME] order) showed a recommendation .[MEDICATION NAME] 0.5 mg q (every) 12 hours prn anxiety .All PRN [MEDICAL CONDITION] orders to be complete should include drug, dose, schedule and PRN Reason to give and only 14 day duration. Please d/c (discontinue), add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician replied .Continue PRN dt (due to) SOB (shortness of breath), Anxiety. PRN dose necessary for comfort . Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's Order Summary Report showed orders written 12/31/2019 for [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg every 4 hours as needed for anxiety, and [MEDICATION NAME] 0.5 mg 2 tablets every 4 as needed for anxiety and air hunger, with no documentation of when the [MEDICATION NAME] was to be discontinued. Review of the admission MDS dated [DATE] showed Resident #29 had moderate cognitive impairment, received antianxiety and antidepressant medications, and received hospice services. Review of a Consultant Pharmacist Communication dated (MONTH) 2020 for the [MEDICATION NAME] 1 mg every 4 hours prn showed, .Please d/c, add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician's response dated 2/6/2020 (over 1 month after the order was written) stated .(Resident #29) Has periodic anxiety in which a longer dose is necessary. Under Hospice care. Necessary for patient's comfort . Review of a Consultant Pharmacist Communication dated (MONTH) 2020 for the [MEDICATION NAME] 0.5 mg every 4 hours prn showed, .Please d/c, add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician's response dated 2/6/2020 (over 1 month after the [MEDICATION NAME] order was written) stated .Hospice Care. Has periodic episodes of Anxiety in which [MEDICATION NAME] is necessary. Necessary for patient's comfort . Interview with the Director of Nursing (DON) on 2/26/2020 at 2:58 PM, confirmed Resident #26 and Resident #29 had PRN antianxiety MEDICATION ORDERS FOR [REDACTED].",2020-09-01
988,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,807,D,0,1,HJSI11,"**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 provide water and ice at the bedside for 1 resident (Resident #6) of 14 residents reviewed. The findings include: Review of the facility policy titled, Safe Distribution of Water and Ice, undated, showed .Pass fresh ice water to residents three times daily, approximately every eight hours and prn (as needed) . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact. During observation and interview on 2/23/2020 at 11:35 AM, in the resident's room, Resident #6 stated the facility did not regularly fill up the water pitchers. The resident had 2 water pitchers in the room and both pitchers were empty. Observation on 2/24/2020 at 9:07 AM, in the resident's room, showed 2 water pitchers in the room and both pitchers were empty. During an interview on 2/24/2020 at 3:09 PM, Registered Nurse (RN) #1 confirmed Resident #6 preferred to have 2 water pitchers. The resident preferred one water pitcher to have ice in it to pour soda over and the other water pitcher to have ice and water. During interview and observation on 2/24/2020 at 3:34 PM, Resident #6 confirmed she wanted water and ice in one water pitcher, and only ice in the other pitcher, so she could pour soda in it. One water pitcher had ice with a small amount of water and the other water pitcher was empty. During an interview on 2/24/2020 at 5:26 PM, the Director of Nursing confirmed it was her expectation for ice and water to be passed every shift to the residents.",2020-09-01
992,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,880,D,0,1,HJSI11,"**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 follow infection control practices for 1 resident (Resident #6) of 14 sampled residents. The findings include: Review of the facility policy titled, Isolation- Categories of Transmission-Based Precautions, revised 1/2012, showed .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions .implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment .wear gloves .when entering the room .remove gloves before leaving the room and perform hand hygiene .wear a disposable gown upon entering the Contact Precautions room . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's order dated 2/24/2020 showed the resident required isolation with Contact Precautions due to an infection in a wound. Observation of Resident #6's room on 2/25/2020 at 7:30 AM, showed a Contact Isolation sign was on the resident's door. The Social Service Director (SSD) was observed in the resident's room with no gloves or gown on. The SSD exited the room carrying juice in her hand, without performing any type of hand hygiene. Interview with the SSD confirmed there was a Contact Isolation sign on the door. The SSD confirmed she had not donned gloves or gown prior to entering the room, and had not performed any type of hand hygiene prior to exiting the room. During observation of wound care for Resident #6 on 2/25/2020 at 3:02 PM, 2 Licensed Practical Nurses (LPN) donned gloves and gowns prior to entering the resident's room. LPN #3 exited the room at 3:07 PM still wearing the gown and gloves. She re-entered the room at 3:08 PM with the same gown and gloves on, and carrying a package of incontinence wipes to provide incontinence care to the resident. LPN #3 then removed the dirty gloves she had on and put clean gloves on, without performing hand hygiene. LPN #3 exited the room again at 3:14 PM to obtain gauze to clean a wound. She removed her gloves, but did not remove the gown prior to exiting the room, and did not perform any type of hand hygiene. LPN #3 exited the room again at 3:21 PM to obtain a measuring device to measure a wound. She removed her gloves prior to leaving the room, but did not remove her gown. LPN #3 exited the room again at 3:25 PM to obtain a dressing for one of the resident's wounds. She removed the gloves, but did not remove the gown. LPN #3 returned to the room at 3:26 PM and donned clean gloves, without performing any type of hand hygiene. During an interview on 2/25/2020 at 3:32 PM, LPN #3 confirmed she had exited the room [ROOM NUMBER] times during wound care to obtain supplies, without removing her gown, and did not always perform hand hygiene prior to exiting the room or with glove changes. During an interview on 2/25/2020 at 4:43 PM, the Director of Nursing confirmed it was her expectation for staff to remove the gown and gloves and to wash the hands prior to exiting an isolation room.",2020-09-01
996,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-09-25,600,D,1,0,ZR0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse for 1 resident (#2) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Neglect, Mistreatment and Misappropriation of Resident Property, last revised 10/2017, revealed .it is the policy of this facility to prevent abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pair or mental anguish .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 7/27/19 revealed on 7/27/19 at approximately 11:00 AM Resident #6 entered Resident #2's room. Further review a nurse entered Resident #2's room after hearing the residents cursing loudly. Continued review revealed as the nurse was removing Resident #6 from Resident #2's room; Resident #6 reached over and hit Resident #2 on the foot. Further review revealed the nurse grabbed Resident #6's arm and placed it close to his body, but Resident #6 quickly reached back and hit Resident #2's foot again. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to .resident is rarely/never understood . Review of a Staff Assessment for mental status revealed the resident's short and long memory was good. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #6's Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Observation and interview with Resident #2 and Licensed Practical Nurse (LPN) #1 on 9/23/19 at 10:20 AM, in the hallway outside the resident's room, revealed the resident was seated in a wheelchair, was well groomed, and had no anxious or fearful behaviors. Interview with Resident #2 revealed .(Resident #6) hit my foot (translated by LPN #1) . Telephone interview with LPN #2 on 9/23/19 at 1:40 PM revealed .He (Resident #6) was in (Resident #2's) room visiting her roommate .(Resident #2) was yelling so I went in the room and was rolling him (Resident #6) out. When we passed the foot of her (Resident #2's) bed he (Resident #6) reached out .hit her (Resident #2's) foot .before I could get (Resident #6's) arms he hit (Resident #2's) foot again .he meant to hit her . Interview with the Director of Nursing on 9/25/19 at 11:18 AM, in the conference room, confirmed Resident #6 deliberately hit Resident #2 on her foot twice. In summary, the facility failed to prevent abuse to Resident #2.",2020-09-01
998,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,657,D,0,1,8C9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility fall investigation, observation and interview the facility failed to revise a care plan for 1 resident (#64) of 32 residents reviewed. The findings included: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physicians Order dated 8/4/12 revealed .up high Back w/c (wheelchair) with Front Back Tip guards with (decreased) safety awareness . Medical record review of the residents care plan dated 8/4/12 revealed .Up in high back w/c with front/back tip guards . Medical record review of the residents care plan last revised 1/10/18 revealed the care plan was not updated to reflect high back wheelchair (w/c) with front and back tip guards. Interview with Licensed Practical Nurse (LPN) #2 on 1/18/18 at 3:00 PM, in the conference room, confirmed the current care plan was not updated to reflect the resident was to use a high back w/c with front and back tip guards.",2020-09-01
999,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,689,D,0,1,8C9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility fall investigation, observation, and interview the facility failed to ensure 1 resident (#64) was free from accidents of 6 residents reviewed for falls. The findings included: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 8/4/12 revealed .Up in high back w/c (wheelchair) with front/back tip guards . Medical record review of a Physicians Order dated 8/4/12 revealed .up high Back w/c with Front Back Tip guards with soft belt . Medical record review of a Physicians Order dated 1/10/18 revealed .send to ER (emergency room ) for eval (evaluation) s/p (status [REDACTED]. Medical record review of a Nurse Practitioner's note dated 1/10/18 revealed .Pt (Patient) is seen today for fall, was in standard wheelchair when she tipped over .Abrasion + (plus) subcutaneous (below the skin) swelling to scalp . Medical record review of a Nurse's note dated 1/10/18 revealed .observed resident up in w/c with w/c lying on it's left side on the floor .raised area to left upper forehead and abrasion noted with active bleeding. Appears that resident struck her head on the bottom of the dresser. Resident was in a standard w/c . Medical record review of the facility investigation dated 1/10/18 revealed .observed resident up in w/c lying on to its left side against the floor .abrasion and raised area noted to left side of upper forehead approx. (approximate) size of quarter .education with staff .19. Was the care plan followed .No .not in high back w/c . Medical record review of an emergency room report dated 1/10/18 revealed XXX[AGE] year old female who presents .after falling out of a wheelchair. Patient sustained an injury to the front of her head .CT scan (Cat scan-test that uses x-ray to provide detailed picture) of her head neck today are unremarkable .She will be treated with a dressing and wound care . Medical record review of the CT report dated 1/10/18 revealed .small left frontal scalp hematoma (collection of blood outside the blood vessell) with no acute intracranial (within the skull) abnormality . Observation of Resident #64 on 1/16/18-1/18/18 revealed the resident was sitting in a high back w/c with anti-tip guards. Continued observation revealed the resident had old bruising to left side of the face. Interview with Licensed Practical Nurse (LPN) #1 on 1/18/18 at 1:00 PM, at the nurse's station, confirmed on 1/10/18 Resident #64 was in a standard 18 inch wheelchair while staff cleaned her high back wheelchair. Continued interview confirmed the resident tipped the w/c over, struck her head, had bruising to her face and an abrasion to her forehead. Further interview confirmed the resident was sent to the hospital for evaluation and confirmed the resident was put in the wrong wheelchair. Interview with Quality Assurance LPN on 1/18/18 at 1:20 PM, in the conference room, confirmed Resident #64 was to be in a high back wheelchair with anti-tip guards. Further interview confirmed on 1/10/18 the resident was put in the wrong wheelchair and tipped it over, causing the resident to hit her head. Continued interview confirmed Resident #64 had an abrasion and bruising to her head, was sent to the hospital for evaluation and returned to the facility.",2020-09-01
1000,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,761,D,0,1,8C9J11,"Based on review of facility policy, observation, and interview the facility failed to ensure medication was disposed of in an appropriate manner. The findings included: Review of the facility policy, Sharps Containers revealed .Disposal of all sharps and medication vial shall be disposed in the sharps container . Observation of the dumpster on 1/16/18 at 11:20 AM, with the Dietary Manager revealed an insulin vial on the ground outside of the dumpster. Continued observation revealed the insulin vial was 1/4 full of clear liquid remaining in the vial. Interview with the Director of Nursing (DON) on 1/17/18 at 11:55 AM, in the conference room confirmed insulin vials are to be disposed of in the sharps containers, and the facility failed to follow their policy.",2020-09-01
1001,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,804,D,0,1,8C9J11,"Based on facility policy review, observation, and interview the facility failed to maintain appropriate food temperatures for 2 of 5 halls observed during the dining process. The findings included: Review of the facility policy, Food Temperatures, undated, revealed .Foods will be served at proper temperature to ensure food safety .Acceptable serving temperatures are: Meat, entrees (greater than) 140 (degrees) but preferably 160-175 (degrees) .Hazardous salads and desserts (less than) 41 (degrees) . Milk, Juice (less than) 41 (degrees) . Observation of dining on the 300 and 400 hallways revealed an insulated cart arrived on 1/17/18 at 11:56 AM for food delivery. Further observation revealed, 2 trays remained undelivered at 12:30 PM. Observation of 1 of the 2 remaining trays at 12:38 revealed the following temperatures: chicken patty 108 degrees F (Fahrenheit); potato salad 60 degrees F; milk 48 degrees F; and mighty shake 48 degrees F. Interview with the General Manager of Dietary Services on 1/17/18 at 12:42 PM, at the 300 and 400 hall nurse's station, confirmed foods were not maintained at proper temperatures.",2020-09-01
1002,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2019-02-06,554,D,0,1,K7LC11,"**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 properly assess 1 resident (#60) for self-administration of medications of 45 residents sampled. The findings include: Review of facility policy Self-Administration of Medication, revised 5/2018, revealed .Storage of medications in the resident's room must be such that it will prevent access by other residents .Only the medications permitted for self-administration shall be left at the bedside . Medical record review revealed Resident #60 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 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Medical record review of the physician's recapitulation orders dated 2/1/19-2/28/19 revealed no documentation of an order for [REDACTED]. Observation of Resident #60 on 2/4/19 at 10:40 AM, in the resident's room, revealed a bottle of over the counter eye drops and a bottle of over the counter saline nasal spray on the resident's over bed table. Observation of Resident #60 on 2/5/19 at 8:13 AM, in the resident's room, revealed the bottle of eye drops and the bottle of saline nasal spray remained on the resident's over bed table. Observation and interview of Resident #60 on 2/5/19 at 2:02 PM, in the resident's room, revealed the bottle of eye drops and the bottle of saline nasal spray remained on the resident's over bed table. Interview revealed .I buy those . Interview and interview with Licensed Practical Nurse (LPN) #1 on 2/5/19 at 2:20 PM, at the nurse's station, revealed the bottle of eye drops and the saline nasal spray were on the resident's over bed table. Interview confirmed Resident #60 was not assessed for self-administration of medications or assessed to keep medications at the resident's bedside. Interview with the Director of Nursing (DON) on 2/5/19 at 2:45 PM, in the DON's office, confirmed the facility failed to assess Resident #60 for self-administration of medications.",2020-09-01
1003,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2019-02-06,695,D,0,1,K7LC11,"**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 ensure respiratory equipment was maintained for 2 residents (#19 and #90) of 14 residents reviewed for respiratory therapy of 45 sampled residents. The findings include: Review of facility policy Equipment Change-Out, revised 7/2017, revealed .The following list of equipment is handled as follows: Changed weekly .Cannula .Humidifier . Medical record review revealed Resident #19 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 the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident received oxygen (O2) therapy. Medical record review of the Physician Standing Orders dated 2/2/19 revealed .Change O2 .tubing weekly and PRN (as needed) . Observation of Resident #19 on 2/4/19 at 10:24 AM, in the resident's room, revealed the resident was receiving O2 at 2 liters per minute (2l/m) by nasal cannula (BNC) and a prefilled humidifier bottle was attached to the O2. Continued observation at 3:12 PM revealed the prefilled O2 humidifier bottle was empty and dated 1/12/19 (25 days prior). Observation of Resident #19 on 2/5/19 at 7:48 AM, in the resident's room, revealed the resident was on O2 at 2 l/m BNC and the prefilled humidifier bottle was attached to the O2. Continued observation revealed the prefilled O2 humidifier bottle was empty and dated 1/12/19. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #90 scored a 14 on the BIMS indicating the resident was cognitively intact. Continued review revealed the resident received O2 therapy. Medical record review of the physician's recapitulation orders dated 1/17/19 through 1/31/19 revealed .Oxygen @ (at) 2 LPM (liters per minute) change O2 tubing weekly & (and) PRN . Observation of Resident #90 on 2/4/19 at 11:17 AM, in the resident's room, revealed the resident was receiving O2 at 2 l/m BNC and a prefilled humidifier bottle was attached to the O2. Continued observation revealed the O2 nasal cannula tubing was dated 1/22/19 (15 days prior) and the prefilled O2 humidifier was not dated. Observation of Resident #90 on 2/5/19 at 7:50 AM, in the resident's room, revealed the resident was receiving O2 at 2 l/m BNC and a prefilled humidifier bottle was attached to the O2. Continued observation revealed the O2 nasal cannula tubing was dated 1/22/19 and the prefilled O2 humidifier bottle was not dated. Interview with Licensed Practical Nurse (LPN) #2 on 2/5/19 at 4:36 PM, on the 200 hallway, confirmed Resident #19's prefilled humidifier bottle was empty and was not in date. Continued interview confirmed Resident #90's O2 nasal cannula tubing was not in date and the prefilled humidifier bottle was not dated. Interview with the Director of Nursing (DON) on 2/6/19 at 7:39 AM, in the conference room, confirmed the facility failed to follow the facility's policy.",2020-09-01
1005,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-02-26,842,D,1,0,ZK7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interview, the facility failed to maintain accurate medical records for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview Mental Status score of 14 (cognitively intact). Continued review revealed the resident required extensive assist with transfers and personal hygiene with 2 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Interview with Licensed Practical Nurse #3 on 2/23/28 at 5:30 PM, at the nurses station revealed .I was told in report by (named Registered Nurse) her (Resident #1's) admission was done .gave her what (medications) were in the computer .it made medication errors . Interview with Registered Nurse #4 on 2/26/18 at 10:15 AM, in the conference room, revealed .I enter the admission orders [REDACTED].if not the nurse on the floor enters them . Interview with the Director of Nursing on 2/26/18 at 10:30 AM, in the conference room, confirmed the facility failed to reconcile the medications for Resident #1. Further interview confirmed the facility failed to ensure the medical record for Resident #1 was accurate.",2020-09-01
1006,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-06-13,600,D,1,0,ZR5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 2 residents (#4125 and #3936), of 5 residents reviewed for abuse. The findings included: Review of the facility's policy Abuse, Neglect and Misappropriation of Property no date, revealed the facility had a system in place for prevention of Abuse and Misappropriation, including orientation and training of employees, pre-employment screening of potential employees, identification, investigation and reporting of abuse, and protection of residents. Further review of the policy revealed the Policy Statement .It is . policy to prevent the occurrence of abuse .Definitions; Abuse is the willful infliction of injury .resulting in physical .pain or mental anguish . Medical record review revealed Resident # 4125 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was 9, indicating the resident was moderately cognitively impaired. The resident's functional status for self-performance of activities of daily living (ADLs) for bed mobility, transfers, dressing, toilet use, and personal hygiene was extensive assistance with 2+ persons support provided. Medical record review of a psychotherapy note dated 5/15/18, revealed .staff reports periods of tremors and possible [MEDICAL CONDITION] activity .PCP (primary care Physician) added PRN (as needed) [MEDICATION NAME] (an antianxiety medication) .staff reports no tremor recently .it is thought at times an attention seeking behavior .review of systems .delusions, mild irritability/anger, decreased attention/concentration, and moderate executive dysfunction . plan of care: continue current medications . may consider a GDR (gradual dose reduction) at next visit, will continue to monitor . Medical record review of the resident's Care Plan dated 10/3/17, revealed .I have behaviors such as verbal/physical towards staff. I wander when up .I also have delusions and hallucinations. I have an [MEDICAL CONDITION]. MR and [MEDICAL CONDITION] and I like to get into dirty trays with food on them and pilfer through them and eat what I want. I also go into others rooms and take their stuff and eat it and drink their drinks; Goal: I will not harm themselves or others secondary to their behaviors through 9/7/18 .approach supervise activities during the day/redirect as needed .discourage me from taking .eating off dirty trays . Medical record review revealed Resident # 3936 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 15, indicating the resident was cognitively intact. The resident's functional status for self-performance of activities of daily living (ADLs) for bed mobility, transfers, dressing, toilet use, and personal hygiene was extensive assistance with 2+ persons support provided. Medical record review of a psychotherapy note dated 4/24/18, revealed the resident mild geriatric depression and anxiety about her future, willingly participated in the psychotherapy sessions and had no behavioral aggressive issues. Review of the facility investigation of the abuse incident between Resident #4125 an Resident #3936,dated 5/16/18, revealed the facility notified all parties and the State Agency promptly, assessments were completed on Resident #4125 and Resident #3936 and no injuries were found. The facility performed skin assessments for residents with a BIMS of less than 8 (moderate to cognitively impaired) and interviews with residents with a BIMS of 8 (moderate to cognitively intact) or greater were completed with no other findings of abuse. The Dietary staff was educated on placing all open food tray trolleys in the dish washing area in order to prevent any resident from eating off returned trays. The Nursing staff was educated on making sure the involved residents were returned to their rooms after meals. Observation of the tray carts after dinner on 6/11/18, after breakfast and lunch on 6/12/18, and after breakfast and lunch on 6/13/18 revealed no open tray carts had been left in the dining room available for residents, all open tray carts had been stored in the dish washing area of the kitchen. Interview with Resident #3936 on 6/12/18, at 9:45 AM, in the resident's room revealed the resident recalled the incident with Resident #4125 in the dining room on 5/16/17 and stated Resident #4125 had hit her on her shoulder lightly after she told her to stop eating that garbage from the trays. The resident then stated she hit Resident #4125 back on her shoulder .she said I slapped her face but I hit her shoulder because anybody that hits me is going to get hit back . Interview with the Dietary Aide on 6/12/18, at 2:30 PM, in the conference room revealed she overheard, did not see, the altercation between Resident #4125 and Resident #3936 on 5/16/18 at approximately 6:30 PM. The Dietary Aide went into the dining room and separated the 2 residents and moved the open tray cart into the kitchen out of the way. The Dietary Aide stated the residents went back to their rooms after the incident and she saw Licensed Practical Nurse (LPN) #1 in the hall and told her what had happened between the residents. Interview with Resident #4125 on 6/13/18, at 8:10 AM, at the Nurses' station revealed the facility was giving her good care and she had no complaints. The resident appeared well groomed and clean and her skin was clear. The resident did not remember the incident with Resident # on 5/17/18. Interview with the Director of Nursing (DON) on 6/13/18, at 12:20 PM, in the conference room revealed LPN #2 had called the DON and the Administrator on 5/16/18,about the incident and the investigation was initiated. The DON stated she had interviewed Resident #4125 and the resident told her Resident #3936 had hit her, the DON questioned the resident if she had hit the other resident first and she replied she had. The DON stated the Assistant DON interviewed Resident #3936 about hitting Resident #4125 and she immediately affirmed she had hit her back. Interview with the DON and the Administrator on 6/13/18, at 12:30 PM, confirmed the facility had failed to prevent the abuse between Resident #4125 and Resident #3936.",2020-09-01
1007,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-09-25,607,D,1,0,15FE11,"**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 interview, the facility failed to intervene promptly during an alleged incident and failed to report an allegation of abuse timely for 1 resident (#1) of 5 residents reviewed for abuse and neglect. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation of Property, undated, revealed .Every Stakeholder .must intervene immediately, to the extent feasible and consistent with personal safety .and training .to prevent or interrupt an incident of abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. Review of a facility investigation dated 9/3/18 revealed Licensed Practical Nurse (LPN) #2 alleged she observed LPN #1 roughly handle and verbally demean Resident #1. Continued review revealed LPN #2 did not intervene promptly during the incident and waited until LPN #1 clocked out at the end of the shift (approximately 2 hours) before she reported the incident to the Director of Nursing (DON). Interview with LPN #2 on 9/24/18 at 2:16 PM, in the conference room, confirmed she witnessed the alleged incident between Resident #1 and LPN #1, but did not intervene immediately. Further interview confirmed LPN #2 did not report the incident timely to the DON. Interview with the DON on 9/24/18 at 3:30 PM, in the conference room, confirmed the facility failed to follow facility policy.",2020-09-01
1008,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2017-10-10,332,D,0,1,9QT011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview the facility failed to administer medications as ordered by the physician for 2 medications of 30 medications observed, resulting in a medication error rate of 6.6 % (percent). The findings included: Review of the facility policy, Medication Administration General Guidelines, dated 12/2012, revealed .Medications are administered as prescribed .prior to administration .review and confirm MEDICATION ORDERS FOR [REDACTED].medications are administered in accordance with written orders of the prescriber .obtain and record any vital signs .prior to medication administration . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physicians Orders dated 10/1/17 - 10/31/17 revealed .[MEDICATION NAME] HCL (skeletal muscle relaxant) 6 mg (milligram) .PO (by mouth) three times daily .[MEDICATION NAME] (medication used to treat high blood pressure, chest pain, and migraines) 40 mg (milligram) orally four times daily .headache .hold for SBP (systolic blood pressure) Observation of Licensed Practical Nurse (LPN) #1 on 10/9/17 at 7:45 AM, in Resident #53's room of a medication administration revealed LPN #1 administered [MEDICATION NAME] 2 mg. Continued observation revealed LPN #1 administered [MEDICATION NAME] 40 mg. Further observation revealed LPN #1 did not obtain a blood pressure or heart rate prior to the administration of the [MEDICATION NAME]. Interview with LPN #1 on 10/10/17 at 8:15 AM, at the nurse's station, confirmed Resident #53 was ordered [MEDICATION NAME] 6 mg. Further interview confirmed LPN #1 administered [MEDICATION NAME] 2 mg and failed to administer the correct dose. Continued interview confirmed LPN #1 failed to obtain blood pressure and heart rate prior to the administration of the [MEDICATION NAME].",2020-09-01
1010,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2017-10-10,441,D,0,1,9QT011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to follow infection control practices during medication administration for 2 of 30 opportunities, affecting Residents #53 and #23. The findings included: Review of the facility policy, Medication Administration General Guidelines, dated 12/2012, revealed .medications are administered .in accordance with .good nursing principles and practices .hands are washed with soap and water and gloves applied before administration of topical .ophthalmic .hands are washed with soap and water again after administration and with any resident contact .antimicrobial sanitizer may be used . Review of the facility policy Medication Administration Subcutaneous Insulin, dated 5/2016, revealed .administer subcutaneous (injection under the skin) insulin .in a safe .manner .perform hand hygiene .put on gloves .inject insulin slowly .remove gloves .perform hand hygiene . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Order dated 10/1/17-10/31/17 revealed Resident #53 was ordered .Insulin (medication to treat Diabetes) . 5 units SUBQ (subcutaneous, an injection given under the skin) three times daily with meals . Observation of Licensed Practical Nurse (LPN) #1 on 10/9/17 at 7:55 AM, in Resident #53's room, revealed LPN #1 administered insulin 5 units subcutaneous (SUBQ). Continued observation revealed LPN #1 failed to apply gloves prior to administering the insulin injection. Interview with LPN #1 on 10/9/17 at 8:10 AM, in the 500 hallway, confirmed she failed to apply gloves prior to administration of the insulin injection. Medical record review revealed Resident #23 was admitted to facility on 3/2/17 with [DIAGNOSES REDACTED]. Medical record review of Physician's order dated 10/1/17-10/31/17 revealed an order for [REDACTED]. Observation of LPN #1 on 10/9/17 at 8:25 AM, in the 500 hallway, revealed LPN #1 applied gloves before entering Resident #23's room. Continued observation revealed LPN #1 removed a [MEDICATION NAME] (medication used to treat pain) from the resident's right arm. Further observation revealed LPN #1 with gloves still applied, discarded the [MEDICATION NAME] in a sharps container at the medication cart in the 500 hallway. Continued observation revealed LPN #1 removed the gloves after discarding patch and re-entered Resident #23's room without washing or sanitizing the hands. Further observation revealed LPN #1 applied gloves and administered [MEDICATION NAME] eye drops to Resident #23. Interview with LPN #1 at 8:35 AM, in the 500 hallway, confirmed she failed to wash hands after removing gloves. Interview with the Director of Nursing (DON) on 10/9/17 at 3:20 PM, in the conference room, confirmed LPN #1 failed to follow infection control practices during medication administration.",2020-09-01
1011,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2019-10-23,600,D,1,1,UOSR11,"**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 ensure 2 residents (#10 and #53) were free from abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed .Abuse .includes physical abuse .Willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical abuse .includes, but not limited to, hitting, slapping, pinching, kicking . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 7/9/19 revealed .increased behaviors noted this shift toward staff when trying to redirect resident or provide care . Medical record review of Resident #10's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #231's Quarterly MDS dated [DATE], revealed the resident was rarely understood. Review of the facility Event Report dated 8/2/19, revealed Resident #231 approached Resident #10 in her wheelchair and struck him with an open hand. Continued review revealed no injury occurred. Interview with Certified Nursing Assistant (CNA) #1 on 10/22/19 at 2:45 PM, in the conference room, confirmed on 8/2/19 she observed Resident #231 in her wheelchair pushing herself by the shower room in the 300 hallway. Continued interview confirmed Resident #231 pushed her w/c up to Resident #10 and struck Resident #10 on the arm with her (Resident #231) hand. Interview with CNA #2 on 10/22/19 at 3:00 PM, in the conference room confirmed on 8/2/19 she observed Resident #231 push her w/c up to Resident #10 and slapped him on the arm. Further interview confirmed Resident #231 had become agitated with staff and residents prior to the incident on 8/2/19 . Interview with the Nurse Consultant on 10/23/19 at 3:25 PM, in the conference room, confirmed there was a resident to resident altercation between Resident #231 and Resident #10 on 8/2/19. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review of Resident #41's nurse's note dated 8/12/19 revealed .had a negative interaction with another resident back on the gate (gated) community .they were in each other's personal space . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed assure Resident #53 was free from abuse.",2020-09-01
1012,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2019-10-23,609,D,0,1,UOSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report abuse for 1 resident (#53) of 24 residents reviewed. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19, revealed .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of Resident #41's nurse's note dated 8/12/19 revealed .had a negative interaction with another resident back on the gate (gated) community . Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Medical record review of Resident #53's Event Report dated 8/12/19, revealed .DESCRIPTION .RESIDENT TO RESIDENT ALTERCATION 8/12/2019 . Further review revealed .DON (Director of Nursing) notified .Yes . Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed to report the incident of abuse that occured on 8/12/19. Refer to F-600",2020-09-01
1013,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2019-10-23,610,D,0,1,UOSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to investigate abuse for 1 resident (#53) of 24 residents reviewed for abuse. The findings include: Review of facility policy,Abuse, Neglect, and Missappropriation of Property revised 5/8/19 revealed .The Facility Administrator will investigate all allegations, reports .incidents .may delegate .the investigation to the Director of Nursing .the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Medical record review of Resident #53's Event Report dated 8/12/19, revealed .DESCRIPTION .RESIDENT TO RESIDENT ALTERCATION 8/12/2019 . Further review revealed .DON (Director of Nursing) notified .Yes . Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed to investigate the incident of abuse that occured on 8/12/19. Refer to F-600 and F-609",2020-09-01
1014,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2019-10-23,842,D,0,1,UOSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical record review and interview the facility failed to ensure the Tennessee Physician order [REDACTED].#283) of 24 residents reviewed. The findings include: Review of the Tennessee Physician order [REDACTED].To be valid. POST must be signed by a physician . Medical record review revealed Resident #283 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Interview with Assistant Director of Nursing (ADON) #2 on 10/23/19 at 10:00 AM, on the 600 hallway, revealed POST forms .are to be filled out on admission by the resident or designated party .The original form (POST) goes on the chart and a copy goes in the physician box to be signed . Continued interview confirmed the physician failed to sign and date the resident's POST form.",2020-09-01
1015,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-10-24,641,D,0,1,5YLW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to accurately assess the Brief Interview for Mental Status (BIMS) on the Minimum Data Set (MDS) for 1 resident (#25) of 32 residents reviewed for MDS. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #25 had a BIMS score of 15, indicating the resident was cognitively intact. Medical record review of a care plan dated 6/5/17 and updated 8/23/18 revealed Resident #25 had impaired cognitive skills, difficulty with communication needs, and was non-verbal. Observations of Resident #25 on 10/22/18 at 10:04 AM, and 2:20 PM, in the resident's room, revealed the resident was non-verbal and would occasionally respond to yes or no questions by the blinking or rolling of the eyes. Interview with Certified Nursing Assistant (CNA) #2 on 10/23/18 at 1:00 PM, on the 500 Hall, confirmed the resident was non-verbal .the last 3 years I've been here . Interview with Licensed Practical Nurse (LPN) #2 on 10/23/18 at 1:05 PM, at the nurses' station, confirmed the resident was non-verbal and did not write. Continued interview confirmed the resident communicated by way of rolling the eyes up or down. Interview with the Social Service Director (SSD) on 10/23/18 at 1:15 PM, in the MDS office, confirmed the resident was non-verbal and unable to communicate. Continued interview confirmed the BIMS score of 15 entered on the MDS was inaccurate and in error.",2020-09-01
1016,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-10-24,693,D,0,1,5YLW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to administer enteral feedings (liquid nutrition provided through a tube inserted into the stomach) as ordered for 1 resident (#25) of 3 residents reviewed for enteral feedings of 32 sampled residents. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 required total dependence of 2 with bed mobility, dressing, eating, toileting and personal hygiene. Further review revealed the resident received nutrition through an enteral feeding (feeding tube). Medical record review of a care plan dated 6/5/17 and updated 8/28/18 revealed Resident #25 required a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically inserted into the stomach through the abdomen in which liquid nutrition can be delivered) with approaches to .Provide Peg tube feedings/flushes as ordered .(increase) Tube feedings as ordered . Medical record review of a physician's orders [REDACTED].Increase TWO CAL (nutritional supplement) rate to 50 ml/hr (milliliters per hour) x (times) 22 hrs (hours) . Medical record review of the Physician's Recapitulation Orders dated 10/8/18 revealed .Two Cal rate 50 ml/hr for 22 hrs, Decrease H20 (water) autoflush to 29 ml/hr for 22 hours . Medical record review of the Medication Administration Record [REDACTED].Two Cal rate 50 ml/hr for 22 hours. Decrease H20 autoflush to 29 ml/hr . Observation of Resident #25 on 10/22/18 at 10:16 AM, 2:12 PM, 2:29 PM, and 3:40 PM, in the resident's room, revealed the resident's tube feeding was infusing via (by way of) pump at 45 ml/hr with 30 ml/hr water flush and not the ordered 50 ml/hr with the ordered 29 ml/hr water flush. Observation of Resident #25 on 10/23/18 at 7:25 AM, 12:40 PM, and 2:00 PM, in the resident's room, revealed the resident's tube feeding of Two Cal was infusing via pump at 45 ml/hr with 30 ml/hr water flush. Observation and interview with the Director of Nurses on 10/23/18 at 2:00 PM, in the resident's room, confirmed the tube feeding flow rate was infusing at 45 ml/hr and not the ordered 50 ml/hr. Continued interview confirmed the H20 flush was infusing at 30 ml/hr and not the ordered 29 ml/hr flow rate.",2020-09-01
1017,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-10-24,695,D,0,1,5YLW11,"**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's order for administration of oxygen for 1 resident (#25) of 6 residents reviewed for respiratory care of 32 sampled residents. The findings include: Facility policy review of the Oxygen Administration Policy revised 9/6/18 revealed .Guideline Steps .Turn on the oxygen per MD (Medical Doctor) order .Adjust the oxygen delivery device so .the proper flow of oxygen is being administered .Documentation .rate of oxygen flow . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 required total dependence of 2 staff with bed mobility, dressing, eating, toileting and personal hygiene and the activity of transfers and locomotion did not occur. Continued review revealed the resident received oxygen therapy. Medical record review of a care plan dated 6/5/17 and updated 8/23/18 revealed Resident #25 had a potential for difficulty breathing due to [MEDICAL CONDITION] and a history of aspiration pneumonia with approaches to .Administer Oxygen per md (medical doctor) orders see MAR (Medication Administration Record) . Medical record review of the MAR indicated [REDACTED]. Medical record review of the Physician's Recapitulation Order dated 10/8/18 revealed no order for oxygen or an oxygen flow rate. Observations of Resident #25 on 10/22/18 at 10:04 AM, and 2:20 PM, in the resident's room, revealed the resident lying in bed. Continued observation revealed the resident had oxygen (02) in use at 3.5 liters per minute (l/m) by nasal cannula (bnc). Observations of Resident #25 on 10/23/18 at 7:25 AM, and 12:40 PM, in the resident's room, revealed the resident lying in bed. Continued observation revealed the resident had 02 in use at 3 l/m bnc. Observation and interview with the Director of Nurses on 10/23/18 at 2:00 PM, in the resident's room, confirmed the resident had 02 in use at 3 l/m bnc. Continued interview confirmed there was not a Physician's Order for the oxygen or oxygen flow rate.",2020-09-01
1020,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,580,D,1,0,DJ7L11,"**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 interview, the facility failed to report a change in resident condition timely to the Physician for one resident (#5) of 4 residents reviewed for change in condition of five sampled residents. The findings included: Review of the facility policy Change of Condition, undated, revealed .The facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay information to the physician and to document actions to include but not limited to .significant change in the residents physical .status .need to alter treatment .decision to transfer .accident which results in injury .or has potential .requiring physician intervention .document in the medical record the physician .notification .notify the resident's representative .of change .and follow through completed .in the medical record .follow up documentation by the licensed nurse .should continue .following onset of the change or as ordered by the physician .address .change on the 24 hour report .update the care plan . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had short and long term memory loss, was chair or bedfast, and required maximum assistance of 2 persons for all activities of daily living. Review of a facility investigation dated 11/30/18 revealed on 11/29/18 at approximately 2:00 AM Resident #5 was noted by Certified Nurse Aide (CNA) #3 to have increased discomfort during personal care. Continued review revealed CNA #3 noted [MEDICAL CONDITION] in the resident's right leg above the knee joint and a dried spot of blood on the resident's left shin. Further review revealed CNA #3 reported the symptoms Licensed Practical Nurse (LPN) # 2 and LPN #2 assessed the resident's and noted the findings on the 24 hour report form. Continued review revealed LPN #2 did not notify the Physician of the resident's change in condition. Further review revealed at approximately 4:00 AM CNA #3 noted the resident's right knee had increased swelling and the resident had increased discomfort. Continued review revealed CNA #3 reported the resident's condition to LPN #2 who assessed the resident again, but did not report the change in condition to the physician. Further review revealed the resident's condition was not immediately reported to the Director of Nursing (DON) or Administrator by the oncoming nurse, but the resident's change in condition was discussed in the daily morning meeting which included Assistant Directors of Nursing (ADON) #1 and #2. Continued review revealed ADON #1 and ADON #2 completed the morning meeting but did not assess Resident #5 or notify the Physician of Resident #5's condition until around 1:30 PM on 11/29/18 (11.5 hours later) when staff reported Resident #5 exhibited increased swelling to her right leg and had abrasions on her left knee. Further review revealed ADON #1 notified the physician and obtained an order for [REDACTED]. Interview with the Administrator and Director of Nursing (DON) on 12/17/18 at 6:00 AM, in the conference room, confirmed the facility failed to notify Resident #5's physician timely of the change of condition and the facility failed to follow facility policy.",2020-09-01
1021,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,761,D,1,0,DJ7L11,"> Based on review of facility policy, observation, and interviews, the facility failed to follow established procedures for narcotic drug reconciliation counts on 1 medication cart (#1) of 5 medication carts reviewed on 1 hallway (#400) of 5 hallways reviewed. The findings included: Review of the facility policy Controlled Medication and Drug Diversion, undated, revealed .At each shift change or when keys are rendered, a physical inventory of all controlled medications is conducted by two staff: licensed nurse .or per state regulation and is documented .this is completed as follows .the nurse .surrendering the keys will read from the controlled substance accountability book the name of resident and the medication to be accounted .oncoming nurse .will locate medication .in the narcotic drawer .count remaining medication and report to nurse the amount of the medication remaining .the nurse in charge of the accountability book will verify correct or incorrect .medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage and disposal .in accordance with federal, state and other applicable laws and regulations . Observation of a narcotic drug reconciliation on 12/17/18 at 5:32 AM, on the 400 hallway with Licensed Practical Nurse (LPN) #16 and LPN # 17 revealed LPN #16 and LPN #17 failed to name the resident listed on each narcotic inventory sheet, failed to name each drug counted, and failed to verified the number of remaining narcotic tablets matched the number on the narcotic control logs for each resident during the narcotic drug reconciliation. Interview with the Director of Nursing and Administrator on 12/17/18 at 7:30 AM, in the conference room, confirmed the facility failed to follow procedures for medication reconciliation and failed to follow facility policy.",2020-09-01
1022,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,842,D,1,0,DJ7L11,"**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 document significant changes in resident medical conditions into the medical record for one Resident (#5) of 5 medical record reviewed. The findings included: Review of the facility policy Change of Condition, undated, revealed .The facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay information to physician and to document actions to include but not limited to .significant change in the residents physical .status .need to alter treatment .decision to transfer .resident .accident which results injury .or has potential .requiring physician intervention .document in the medical record the physician .notification .notify the resident's representative .of change .and follow through completed .in the medical record .follow up documentation by the licensed nurse .should continue .following onset of the change or as ordered by the physician .address .change on the 24 hour report .update the care plan . Review of a facility investigation dated 11/30/18 revealed on 11/29/18 at approximately 2:00 AM Resident #5 was noted by Certified Nurse Aide (CNA) #3 to have increased discomfort during personal care. Continued review revealed CNA #3 noted [MEDICAL CONDITION] in the resident's right leg above the knee joint and a dried spot of blood on the resident's left shin. Further review revealed CNA #3 reported the symptoms Licensed Practical Nurse (LPN) # 2 and LPN #2 assessed the resident's and noted the findings on the 24 hour report form. Continued review revealed at approximately 4:00 AM CNA #3 noted the resident's right knee had increased swelling and the resident had increased discomfort. Continued review revealed CNA #3 reported the resident's condition to LPN #2 who assessed the resident again. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had short and long term memory loss, was chair or bedfast, and required maximum assistance of 2 persons for all activities of daily living. Medical record review revealed no documentation of the swelling and pain to Resident #5's leg. Telephone interview with LPN #2 on 12/11/18 at 7:00 PM confirmed she was made aware of Resident #5's symptoms of swelling and pain in the resident's right leg, but she had become distracted and failed to complete the nursing documentation. Interview with the Director of Nursing (DON) on 12/17/18 at 6:00 AM, in the conference room, confirmed there was no documentation of the resident's injury in the medical record.",2020-09-01
1023,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2020-02-06,761,D,0,1,3UYO11,"**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 stored when expired medications and opened and undated medications were observed in 2 of 8 medication storage areas (Medication room [ROOM NUMBER] and Secured Unit Medication Room). Findings include: Review of the facility's policy titled, Storage of Medications, dated 6/23/2016, showed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs .such drugs shall be returned to the dispensing pharmacy or destroyed . 1. Observation of Medication room [ROOM NUMBER] on 2/5/2020 at 7:55 AM, showed a medication refrigerator containing the following expired medications: [REDACTED] a. 3 [MEDICATION NAME] 10 mg suppositories with an expiration date of 5/2019. b. 5 [MEDICATION NAME] suppositories with an expiration date of 6/2019. 2. Observation in the Secured Unit Medication Room on 2/5/2020 at 4:43 PM, showed one opened and undated 16 ounce bottle of Hydrogen Peroxide stored on a shelf. During an interview conducted on 2/5/2020 at 4:47 PM, the Director of Nursing confirmed expired medications and opened and undated medications should not be stored in the medication rooms.",2020-09-01
1024,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2019-03-27,561,D,0,1,SJZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to honor a resident's request related to bathing for 1 of 24 (Resident #46) sampled residents reviewed for choices. The findings include: The facility's Shower/Tub Bath Schedules policy with a revised date of 8/9/17 documented, .The purpose of this procedure is to provide bathing activities per resident preference and needs .The facility will make every effort to meet the residents needs and preferences. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #46 on 3/25/19 at 2:00 PM in Resident #46's room, Resident #46 stated, I am supposed to get showers on Tuesday and Friday and bed baths in between. I haven't had a bath in 12 days . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for decision making and required two person physical assist with bathing. Review of the facility's bathing schedule for the months of (MONTH) 2019 and (MONTH) 2019 revealed Resident #46 did not receive a bath 17 of 28 days in (MONTH) and 18 of 26 days in March. In (MONTH) Resident #46 did not receive a bath on 2/2/19, 2/3/19, 2/6/19, 2/7/19, 2/9/19, 2/11/19, 2/14/19, 2/16/19, 2/17/19, 2/18/19, 2/20/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, and 2/28/19. In (MONTH) Resident #46 did not receive a bath on 3/2/19, 3/3/19, 3/4/19, 3/6/10, 3/7/19, 3/9/19, 3/10/19, 3/11/19, 3/13/19, 3/14/19/ 3/16/19, 3/17/19, 3/18/19, 3/20/19, 3/21/19, 3/23/19, 3/24/19, and 3/25/19. Interview with the Director of Nursing (DON) on 3/26/19 at 1:30 PM, in the Conference Room, the DON was asked to look at the bath report to verify that Resident #46 received a bed bath on the 17 of 28 days in (MONTH) and the 18 of 26 days in March. The DON stated I cannot verify that bath's were given according to the documentation.",2020-09-01
1025,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2019-03-27,641,D,0,1,SJZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the MDS (Minimum Data Set) 3.0 RAI (Resident Assessment Instrument) Manual, medical record review, and interview, the facility failed to accurately assess residents for activities of daily living, psychotrophic medication and pressure ulcers for 3 of 18 (Resident #32, 33, and 39) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v1.16 (MONTH) (YEAR), page G-1, documented .Code extensive assistance (1 or 2 persons): if the resident with tube feeding, TPN, or IV fluids did not participate in management of this nutrition but did participate in receiving oral nutrition. This is the correct code because the staff completed a portion of the ADL activity for the resident (managing the tube feeding, TPN, or IV fluids) . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented Resident #32 received supervision with eating and 51% or more of total calories were received through PEG feeding. The Order Summary Report dated 9/30/18 documented NPO (nothing by mouth) diet .Enteral Feed Order five times a day [MEDICATION NAME] 1.5 237 ml (milliliters) bolus via PEG . Review of the Medication Administration Records (MARs) dated 8/1-31/18 and 9/1-30/18 revealed enteral feedings were administered via the feeding tube 5 times daily as ordered from 8/28-9/3/18. Interview with the MDS Coordinator on 3/27/19 at 8:55 AM in the Conference Room the MDS Coordinator verified that the 9/3/18 MDS had been coded incorrectly. The MDS coordinator stated, .When you asked me for the ADLs for the assessment on (named Resident #32), I realized that eating should have been coded as (extensive) instead of (supervision) . 2. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #33 received seven days of an antipsychotic medication and further documented the resident did not receive antipsychotic medications since admission/entry assessment. The physician's orders [REDACTED].[MEDICATION NAME] Capsule 40mg (Ziprasidone HCI), (a antipsychotic medication) .by mouth three times a day . Interview with the MDS Coordinator on 03/27/19 at 5:04 PM in the Conference Room, the MDS Coordinator was asked if a resident received a pyschotrophic medication on a daily basis, should it be coded on the MDS. The MDS Coordinator confirmed this MDS was inaccurate and stated, The MDS should have been coded to reflect antipsychotics were received on a daily basis. 3. Medical record review revealed Resident #39 was admitted to the facility 11/16/18 with [DIAGNOSES REDACTED]. Review of the wound assessments revealed Resident #39 had a Deep Tissue Pressure Injury (DTPI) that was first observed on 1/16/19 and currently had this wound. The quarterly MDS dated [DATE] documented Resident #39 did not have a pressure injury. Interview with the MDS Coordinator on 03/27/19 at 1:38 PM in the Conference Room, the MDS Coordinator was asked if the MDS assessment dated [DATE] should have been coded for a pressure injury. The MDS Coordinator stated, Yes, Ma'am.",2020-09-01
1026,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2019-03-27,657,D,0,1,SJZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure residents and families were given the opportunity to participate in the development, review and revision of the care plan for 2 of 24 (Resident #30 and 46) sampled residents reviewed for participation in care planning. The findings include: 1. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact for decision making. Interview with Resident #30 on 3/25/19 at 2:15 PM in Resident #30's room, Resident #30 stated, I do not get invited to care plan meetings. No documentation was found in the medical record that Resident #30 had been invited to attend a care plan meeting. 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairments. Interview with Resident #46 on 3/25/19 at 2:00 PM in Resident #46's room, Resident #46 stated, I do not get invited to care plan meetings. No documentation was found in the medical record that Resident #46 had been invited to attend a care plan meeting. Interview with the MDS Coordinator on 3/26/19 at 12:21 PM in the Conference Room, the MDS Coordinator was asked who invited residents and families to care plan meetings. The MDS Coordinator stated, .Social is the one that sends the invitations . Interview with the Director of Nursing (DON) on 3/26/19 at 1:43 PM in the Conference Room, the DON was asked if residents or families should be invited to attend care plan meetings. The DON stated, Yes .Depending on the BIMS we would either send the invitation to the resident or the family . The facility was unable to provide documentation that residents or families were being invited to attend care plan meetings.",2020-09-01
1027,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2017-05-04,280,D,1,0,3EWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to revise the care plan for enteral feedings, pressure ulcers, and interventions to protect from further injury for 3 of 19 (Resident #93,116 and 121) sampled residents reviewed of the 33 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation Data Sheet dated 3/10/17 documented Resident #116 was admitted with a Right (R) abdominal surgical incision, a Left (L) abdominal puncture wound, 3 retention sutures to the middle abdomen, stage 3 pressure area to her coccyx and a stage 1 abraded area around the coccyx wound. The (MONTH) and (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) Medication Administration Record (MAR) documented Resident #116 received [MEDICATION NAME] 1.5 (a tube feeding) as ordered every night, except on 3/13/17 and 3/21/17 when it was documented as refused. The (MONTH) (YEAR) Treatment Administration Record (TAR) documented Resident #116 received wound care to the coccyx and abdominal wounds beginning 3/17/17. The admission care plan 3/10/17 documented, . resident has a PEG (Percutaneous Endoscopic Gastrostomy) tube that is used only for medications .Risk for alteration in skin integrity R/T (related to) mobility status . The surgical wound to the abdomen and the pressure areas to coccyx were not addressed on the care plan. Interview with MDS Coordinator #2 on 5/3/2017 at 2:39 PM, in the conference room, MDS Coordinator #2 was shown a copy of the (MONTH) (YEAR) MAR and asked if the care plan that documented, .PEG .used only for medications . was correct. MDS Coordinator #2 stated, No it is not. MDS Coordinator #2 was shown the wound documentation from (MONTH) (YEAR) and asked if she could find wounds on the care plan. MDS Coordinator #2 stated No, its not on there . 2. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 3/25/17 documented, .Resident was sitting (at) table lying on table noted to have bruised area to forehead on (right) side .will offer pillow when leaning on table to decrease pressure to forehead . Review of the care plan dated 2/28/17 revealed the care plan was not revised to include the intervention to offer a pillow when Resident #121 leans on the table to decrease pressure to forehead. Interview with the Director of Nursing (DON) on 5/3/17 11:35 AM, in the conference room, the DON was asked if the care plan was revised to reflect the intervention to offer a pillow to the resident when she has her head on the table. The DON reviewed Resident #121's care plan and stated, No, it's not.",2020-09-01
1028,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2017-05-04,323,D,1,0,3EWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to perform a timely and thorough investigation and failed to perform neuro checks for 1 of 3 (Resident #121) sampled residents reviewed for skin conditions and accidents. The findings included: 1. The facility's Accidents and Incidents - Investigating and Reporting policy documented, .Regardless of how minor an accident or incident may be, including injuries of an unknown source, it will be reported to the department supervisor .A report of incident/Accident will be completed .The following data .must be included .The name(s) of witnesses and their account of the accident or incident . Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note dated 3/15/17 documented, .Pin size scab noted (right) posterior hand with quarter size bruise . Review of accident investigations for Resident #121 revealed that there was no investigation of the finding of the scab and the bruise on Resident #121's right hand. Interview with the Director of Nursing (DON) on 5/3/17 at 11:35 AM, in the conference room, the DON was asked if an investigation had been completed for the finding of the scab and bruise on Resident #121's right hand. The DON stated, I do not have an investigation for 3/15 for the scab on her hand . Review of a facility investigation report dated 3/25/17 documented, .Resident was sitting (at) table lying on table noted to have bruised area to forehead on (right) side . Interview with Licensed Practical Nurse (LPN) #4 on 5/2/17 at 6:24 PM, in the memory unit, LPN #4 was asked about Resident #121's accident that resulted in a hematoma to her forehead. LPN #4 stated, On 3/25/17 around 8:00 she had been to the shower. (Named Certified Nursing Assistant (CNA) #1), she brought her to the dining room and she showed me a reddened area to her forehead .she had been sitting at the table in the dining room before she went to the shower and (Named CNA #1) noticed it in the shower. She had been sitting at the table with her head down on the table without a pillow or arm support .her face against the table. Nobody saw her hit her head against the table but that's the only thing that we could figure out it was right where she had been laying or if she had bumped her head on the table, that's the spot it would have left She's very confused. She'll be sitting there and suddenly plop her head down. (Named CNA #1) came to get me. Interview with CNA #1 on 5/3/17 at 10:06 AM, in the conference room, CNA #1 was asked about the day she found the bruise on Resident #121's forehead. CNA #1 stated, I came in around 8:15 am, she had her head on the table in the dining room and the other aides were picking up the rest of the breakfast trays. I helped finishing pick up trays. I went back, got her and took her to the central bath in her wheel chair and assisted her to the toilet. While she was sitting on the toilet, I washed her up and changed her clothes and got her dressed for the day. I was doing her hair and I slid my hand across her forehead to pull her hair back so I could wet it, and she cringed, and that's when I noticed the bruise. You could see the bump on the right side of her forehead that was a bluish white color. I finished getting her dressed, put her in her wheelchair and rolled her out of the bathroom. I was standing in the hallway with her in the wheel chair and (Named LPN #4) was at her med cart and I asked her had she seen or did she know (Resident #121) had a bump on her head. And she assessed her . CNA #1 was asked if the facility had her write a statement of the incident. CNA #1 stated, No. Interview with the DON on 5/3/17 at 11:50 AM, the DON was asked if CNA #1 was asked to write a statement for the investigation about Resident #121's forehead bruise. The DON stated, She's the one that got the nurse when she saw it? Yes, she should have. I don't have the statement here so, no. 2. The facility's Neurological Assessment policy documented, .Neurological assessments are indicated .Following .other accident/injury involving head trauma . Review of the medical record revealed there were no neuro checks performed after the bruise was discovered on Resident #121's forehead. Interview with the DON on 5/3/17 at 11:52 AM, in the conference room, the DON was asked if neuro checks were performed for Resident #121 on 3/25/17 when the bruise was found on her forehead. The DON stated, I cannot locate the neuro checks on 3/25.",2020-09-01
1029,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2018-05-16,684,D,0,1,O1UD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the needed skin care and services for 1 of 1 (Resident #2) sampled residents with skin assessments. The findings included: Medical record review revealed Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The incident report dated 4/18/18 documented, .skin tear to L (left) hand . The incident report dated 4/27/18 documented, .Resident had skin tear to L (left) hand from previous fall skin tear reopened requiring resident to be sent to ER (emergency room ) for further treatment . The return to nursing home form dated 4/27/18 documented, .Laceration of L hand .wound care suture removal in 8-10 days . The weekly skin assessments dated 4/20/18, 4/27/18, 5/4/18 and 5/11/18 documented no new abnormal skin areas or any existing abnormal skin area. Observation in the dining room on 5/16/18 at 7:30 AM revealed Resident #2 seated in a wheelchair with a large deep blue to purple bruise and thick brown scab on his left hand. Interview with the Director of Nursing (DON) on 5/16/18 at 10:50 AM in the conference room, the DON was asked if there should have been weekly skin assessments to reflect the bruises and scab on Resident #2's left hand. The DON stated, Yes.",2020-09-01
1030,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2018-05-16,689,D,0,1,O1UD11,"**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 the safety of a resident during transfer and failed to ensure fall interventions were re-evaluated for 2 of 4 (Resident #30 and #59) sampled residents reviewed for falls. The findings included: 1. The facility's Falls-Clinical Protocol policy with a revision date of 4/2016 documented, .The Minimum Data Set (MDS) .will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls .Interventions should be developed and implemented per the assessed needs .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (beside those that have already been identified) and will re-evaluate the continued relevance of current interventions . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, required extensive assistance with 2 person assist with transfers and was total dependence for bathing. The care plan dated 3/11/18 documented, Problem .resident has ADL (activity daily living) and mobility deficits secondary to being a [MEDICAL CONDITION] secondary to spinal cord injury, muscle weakness and spinal stenosis .Interventions .requires total assist of two for transfers. Resident does not ambulate . The Nurse's Notes dated 3/13/18 documented.Needs moderate assist x 1 for eating .x (time) 2 for transfers . Review of the fall investigation dated 5/1/18 revealed Resident #30 was in the shower room and was being transferred from the shower chair to the wheelchair with one person assist and fell during the transfer. Observation in the smoking area on 5/14/18 at 1:52 PM revealed Resident #30 was seated in a wheelchair. Interview with the MDS Coordinator on 5/16/18 at 1:19 PM in the MDS Coordinator office, the MDS Coordinator was asked how Resident #30 should be transferred. The MDS Coordinator stated, .total assist .two for transfer .he can't bear weight .no control of his legs . The MDS Coordinator was asked if Resident #30 was transferred from the shower chair to the wheelchair should he have two people assist him. The MDS Coordinator stated, Yes, Ma'am . Interview with Certified Nursing Assistant (CNA) #1 on 5/16/18 at 3:30 PM, in the conference room, CNA #1 was asked if anyone helped him transfer Resident #30 from the shower chair to the wheelchair on 5/1/18. CNA #1 stated, No ma'am . Interview with the Director of Nursing (DON) on 5/16/18 at 4:50 PM in the DON office, the DON was asked how many people should have transferred resident #30 the day he fell . The DON stated, Two . 3. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS dated [DATE] revealed two or more falls with injury. Review of the incident reports revealed the following falls for resident #59: 1/7/18 with an intervention to offer to toilet the resident after dinner as tolerated. 1/9/18 with an intervention to check his blood pressure every shift times (X) 72 hours 1/23/18 with an intervention to continue to assist the resident to bed after meals and toileting as needed which was the same intervention as 1/7/18 3/30/18 with an intervention to assist the resident to bed after dinner which was the same intervention as 1/23/18 4/16/18 with an intervention to check his blood pressure for 3 days which was the same intervention as 1/9/18 Interview with the DON on 5/16/18 at 1:24 PM in the conference room, the DON was asked if an intervention did not work and the resident continued to fall, should that intervention be re-evaluated and not used again. The DON stated, .Yes.",2020-09-01
1031,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2018-05-16,761,D,0,1,O1UD11,"Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN #2) nurses failed to ensure medications and biologicals were stored safely when medications were left unattended in a resident's room during medication administration. The findings included: The Facility's Storage of Medications policy documented, .Policy Statement .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Observation during medication administration in Resident #51's room on 5/15/18 beginning at 12:49 PM revealed LPN #2 left medication at the bedside unattended while she washed her hands in the bathroom. LPN #2 returned to the bathroom a second time to wash her hands and again left the medication unattended at the bedside. Interview with LPN #2 on 5/15/18 at 6:00 PM in the medication storage room, LPN #2 was asked if she should have left Resident #51's medication unattended at the bedside while she washed her hands. LPN #2 stated, No. Interview with the Director of Nursing (DON) on 5/16/18 at 4:41 PM in the DON office, the DON was asked if medications should be left unattended at a resident's bedside. The DON stated, No .",2020-09-01
1032,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2018-05-16,880,D,0,1,O1UD11,"**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 when 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses failed to perform hand hygiene during medication administration and the facility failed to ensure practices to prevent the potential spread of infection for 1 of 1 ( Resident #2) sampled residents in isolation. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .Personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .Personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .After contact with .medical equipment .in the immediate vicinity of the residents .After removing gloves . Observations on the split hall on 5/15/18 at 8:51 AM, revealed LPN #1 removed an inhaler and glucometer from the cart, entered Resident #52's room, washed her hands, donned gloves and administered an inhaler. LPN #1 removed her gloves, donned gloves, and performed a finger stick. LPN #1 exited the room, disposed of the lancet, cleaned the inhaler and the glucometer, prepared an insulin injection, and re-entered the room, and administered the insulin to Resident #52. Interview with LPN #1 on 5/15/18 at 9:00 AM in the nurse's station, LPN #1 was asked if she should have changed gloves and washed her hands after cleaning the glucometer and before administering insulin. LPN #1 stated, Yes . Interview with the Director of Nursing (DON) on 5/16/18 at 4:41 PM in the DON office, the DON was asked when she would expect the nurses to wash their hands. The DON stated, Every time they go in and every time they go out (of residents rooms) and any medications (before administering medications) . The DON was asked what she expected her staff to do before administering insulin. The DON stated, .to wash their hands . 2. The Facility's Physicians' Medication Orders policy documented, .4. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order . Medical record review revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Facility's Order Summary Report documented, .Contact Isolation .order date 2/16/18 . The progress notes dated 5/6/18 documented, .Resident remains in isolation due to CRE (Carbapenem-resistant [MEDICATION NAME]) in urine . Observation in Resident's #2 room on 5/14/16 at 10:00 AM revealed no isolation precautions. Interview with the DON on 5/16/18 at 5:53 PM in the conference room, the DON was asked if isolation had been discontinued for Resident #2. The DON stated, The hospice nurse called and gave a verbal order on 5/10/18 but the nurse did not follow up and write a written order.",2020-09-01
1033,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2019-08-19,659,D,1,0,WG8Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure the comprehensive care plan was followed for behaviors for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored an 11 on the Basic Interview of Mental Status (BIMS), which indicated moderately impaired cognition for decision making. The Comprehensive Care Plan for Resident #1 dated 8/4/19 documented, .Behaviors (Resident #1 was on the giving end of a resident to resident altercation on 8/4/19): Staff to escort resident, one on one staff to the dining room to e hall dining. And staff are to escort resident back to room, one on one by staff from dining room . Interviews with Certified Nursing Assistant (CNA) #1, #2, #3, Licensed Practical Nurse (LPN) #1, and #2 on 8/19/19, in the Conference Room, CNA #1, #2, #3, LPN #1, and #2 confirmed they did not escort Resident #1 to the dining room on 8/7/19. Interview with LPN #1 on 8/19/19 at 10:25 AM, at the Nurses' Station, LPN #1 stated, .I was at the nursing station and heard hitting and screams .We went into the dining room and the CNA was pulling Ms. (Named Resident #1) out .we immediately placed her on 1:1 observation .If she (Resident #1) is going to eat we (staff) are to escort her to the [NAME] dining so staff can be with her . Interview with the Director of Nursing (DON) on 8/19/19 at 12:10 PM, in the Conference Room, the Director of Nursing (DON) stated, .The staff didn't follow the care plan of escorting resident to the dining room . 2. Medical record review revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed Resident #2 scored an 11 on the BIMS, which indicated moderately impaired cognition for decision making . The Comprehensive Care Plan dated 8/7/19 documented, .Behaviors 8/7/19 resident was on the receiving end of a resident to resident altercation .Check for adverse reaction and monitor for 72 hours for adverse reaction . Review of the Nurses' Notes for Resident #2 dated 8/7/19-8/9/19 revealed there was no documentation of an assessment of adverse reactions or her state of emotional well being. Interview with the DON on 8/19/19 at 12:10 PM, in the Conference Room, the DON confirmed there was no documentation of Resident #2's emotional well being after the incident 8/7/19 for 72 hours. The DON stated, .No documentation .nothing about her emotional well being .",2020-09-01
1034,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-09-18,600,D,1,0,661Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 3 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had no physical behaviors towards others and verbal behaviors of 1 to 3 times during the assessment period. Review of a facility investigation dated 5/29/19 at 8:22 PM revealed Licensed Practical Nurse (LPN) #1 and LPN #2 witnessed a visitor to the facility holding Resident #1's cane perpendicular across Resident #1's chest and pushing Resident #1 across the hall. Continued review revealed the visitor was escorted to the front office by the Social Worker (SW) and the police were called. Further review revealed the visitor was charged with simple assault. Continued review revealed the resident had no injuries. Telephone interview with LPN #1 on 9/17/19 at 12:00 PM revealed she witnessed the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Continued interview revealed the visitor had not been allowed back into the facility. Telephone interview with LPN #2 on 9/17/19 at 12:05 PM revealed she saw the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Interview with the SW on 9/17/19 at 12:10 PM revealed .I saw the visitor with the resident (Resident #1) at the wall .saw the visitor had his (Resident #1's) cane across his (Resident #1's) body holding him against the wall .took the visitor up front .police showed up .the visitor is not allowed back in the building . Interview with the Director of Nursing (DON) on 9/18/19 at 9:00 AM, in the conference room, revealed .I heard a loud noise .went out into the hall and when I looked down the hall the visitor had (Resident #1) up against the wall with his (Resident #1's) cane held to him (Resident #1) at chest level .I called the police .the visitor has not been allowed in the building .",2020-09-01
1035,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-10-02,656,D,0,1,VVN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine from the body) for 1 resident (#71) of 5 residents reviewed for indwelling urinary catheters. The findings include: Review of the Facility's Comprehensive Care Plan Policy, last revised date 7/19/18, revealed .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Medical record review revealed Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].CATH (indwelling urinary catheter) . Medical record review of a Resident's Progress Note dated 8/27/19 revealed, .catheter placed . Medical record review of a physician's orders [REDACTED].CATH CARE EVERY SHIFT . Medical record review of the Comprehensive Care Plan revealed no documentation for the use of an indwelling urinary catheter. Interview with the Minimum Data Set Coordinator #1 on 10/2/19 at 9:16 AM, in the conference room, confirmed the facility had not developed a comprehensive care plan for the use of an indwelling urinary catheter for Resident #71.",2020-09-01
1037,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-10-02,758,D,0,1,VVN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to provide a rationale for the continued use of an as needed (PRN) anti-anxiety medication beyond 14 days for 1 resident (#84) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, [MEDICAL CONDITION] Medications, last revised 9/5/18, revealed .The facility will make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications .A [MEDICAL CONDITION] drug .include .Anti-anxiety .the physician will review the medical record, medical history, and related factors .Documents rationale and [DIAGNOSES REDACTED].e., times 2 weeks) and only for specific clearly documented circumstances . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #84 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed the resident received Antianxiety, and Antipsychotic Medications. Medical record review of the Physician's recapitulation orders dated 12/20/18 and 1/1/19 to 1/31/19 revealed [MEDICATION NAME] (anti-anxiety medication) 0.5 milligram (mg) every 12 hours PRN without a stop date documented. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed Resident #84 received the PRN [MEDICATION NAME] for a total of 42 days (28 days beyond the 14 days). Medical record review of a Physician's .Active Order . form dated 2/28/19 revealed [MEDICATION NAME] 0.5 mg PRN at bedtime without a stop date documented. Medical record review of the MAR's dated from 2/2019 through 7/2019 revealed Resident #84 received the PRN [MEDICATION NAME] 4 months beyond the 14 days without a rationale documented by the Physician. Medical record review of a Physician's Order dated 7/1/19 revealed the PRN [MEDICATION NAME] was discontinued (4 months after the recommended 14 day stop date). Interview with the Director of Nursing (DON) on 10/2/19 at 3:00 PM, in the DON's office, confirmed the Physician had not provided or documented a rationale for the continued use of a PRN [MEDICAL CONDITION] medication beyond the 14 days.",2020-09-01
1038,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-10-02,759,D,0,1,VVN911,"**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 correctly administer medications for 1 resident (#1). The facility had a total of 2 medication errors of 35 opportunities resulting in a 5.71% (percent) medication error rate. The findings include: Review of the facility policy Medication Administration dated 9/2018 revealed .If it is safe to do so, medication tablets may be crushed .when a resident has difficulty swallowing .Long-acting, extended release or [MEDICATION NAME] coated (coated with a substance that prevents the medication from being released until it reaches the small intestine) dosage forms should generally not be crushed: an alternative should be sought . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Order Report dated 9/1/19-10/1/19 revealed an order dated 9/16/19 .aspirin (a medication used to treat pain or thin the blood) tablet, delayed release . Continued review revealed an order dated 9/16/19 .[MEDICATION NAME] (a medication used to treat high blood pressure) tablet extended release 24 hr (hour) . Observation of medication administration with Licensed Practical Nurse (LPN) #1 on 10/1/19 at 8:48 AM, outside Resident #1's room, revealed LPN #1 crushed the [MEDICATION NAME] extended release, and crushed a chewable aspirin, mixed the medications with applesauce, and administered the medications to Resident #1. Interview with LPN #1 on 10/1/19 at 10:46 AM, at the 100 hall nurses station, confirmed Resident #1's aspirin order was for a delayed release tablet and the aspirin administered was a chewable aspirin. Continued interview confirmed the [MEDICATION NAME] order was an extended release tablet and it had been crushed for administration .it's the only way she can swallow it . Interview with the Director of Nursing on 10/01/19 at 2:52 PM, in the linen room, confirmed it was her expectation for delayed release medications to not be crushed. Continued interview confirmed it was her expectation for nurses to notify the physician to obtain an order for [REDACTED].",2020-09-01
1039,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-10-02,880,D,0,1,VVN911,"Based on facility policy review, observation, and interview, the facility failed to maintain infection control practices during 3 of 9 medication administration observations. The findings include: Review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment revised 10/2018 revealed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection .Reusable items are cleaned and disinfected or sterilized between residents . Observation of medication administration on 10/1/19 at 8:38 AM, on the 100 hallway, with Licensed Practical Nurse (LPN) #1 revealed LPN #1 entered a resident's room, placed a pulse oximeter (device placed on the fingertip used to measure the oxygen level in the blood) on the resident's finger, took the pulse oximeter off the resident's finger and laid it on the over bed table while administering the medications to the resident, then placed the pulse oximeter into her pocket and exited the resident's room. Continued observation revealed LPN #1 did not clean or sanitize the pulse oximeter after use. Further observation revealed LPN #1 entered another resident's room, placed the pulse oximeter on the resident's finger, then removed the pulse oximeter and exited the resident's room. Continued observation revealed LPN #1 did not clean or sanitize the pulse oximeter after use. Further observation revealed LPN #1 re-entered the first resident's room, placed the pulse oximeter onto the resident's finger, then removed the pulse oximeter and exited the room. Continued observation revealed LPN #1 placed the pulse oximeter onto the medication cart without cleaning or sanitizing it after use. Interview with LPN #1 on 10/1/19 at 9:04 AM, in the 100 hallway, confirmed the LPN did not clean the pulse oximeter after resident use .not unless their hands are dirty . Interview with the Director of Nursing on 10/2/19 at 1:48 PM, in the conference room, confirmed it was her expectation for the pulse oximeter to be cleaned with disinfecting wipes after use with each resident.",2020-09-01
1040,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,554,D,0,1,8DM911,"**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 complete an interdisciplinary team (IDT) assessment for self-administration of medications for 1 resident (#2) of 5 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of facility policy Medication Administration General Guidelines dated 5/16 revealed .Medications are to be administered at time they are prepared . Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations .The resident is always observed after administration to ensure that the dose was completely ingested . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's current care plan dated 1/27/17 revealed the resident was not documented to self-administer prescribed medications. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of Resident #2's physician's orders [REDACTED].>Medical record review of facility revealed Resident #2 was not reviewed by the Interdisciplinary (IDT) team for self-administration of medications. Observation on 10/8/18 at 11:00 AM, in the resident's private room, revealed the resident was lying in bed watching television alone. Continued observation revealed a 30 ml (milliter) clear plastic medication cup with 10 pills sitting on the resident's bedside table. The cup contained the following medications: [REDACTED] *One Carvedilol 25 milligram (mg) tablet (medication used to treat high blood pressure) *One [MEDICATION NAME] 5 mg tablet (medication to treat high blood sugar) *One Chewable Aspirin 81 mg tablet (medication to prevent blood clots) *One [MEDICATION NAME] 5 mg tablet (medication to treat high blood pressure) *One [MEDICATION NAME] 50 mg tablet (medication used to treat high blood pressure) *One Potassium CL (chloride) ER (extended release) 20 meq (milliequivalent) (medication to treat low blood levels of potassium) *One Calcium Acetate 667mg (medication to prevent high blood phospate) *One [MEDICATION NAME] 120 mg (medication used to treat swelling and high blood pressure) *One Multiple Vitamin with minerals formula (supplement used to improve health) Interview with Resident #2 on 10/8/18 at 11:00 AM, in the resident's room, revealed, .I usually take them (pills at bedside) with lunch .when they are busy they leave them (pills at bedside) . Interview with Licensed Practical Nurse #7 on 10/8/18 at 11:05 AM, outside of Resident # 2's room, confirmed .I did not watch her take all of her pills .I don't leave any meds (medications) but hers (Resident #2) .those were her 9:00 AM meds . Interview with the Director of Nursing on 10/11/18 at 2:20 PM, in the conference room, confirmed .Absolutely not (resident to give own medications) unless self-administration .they (nurses) should not leave medications at bedside .she knew it wasn't policy .",2020-09-01
1041,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,689,D,0,1,8DM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (#68) of 4 residents reviewed for falls of 37 sampled residents. The findings include: Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's Care Plan revised 9/7/18 revealed .At risk for falls .Floor Mat . Observation on 10/9/18 at 8:04 PM, in Resident #87's room, revealed the resident was lying in bed and there was not a floor mat beside the bed. Observation on 10/10/18 at 2:45 PM, in Resident #87's room, revealed the resident was lying in bed and there was not a floor mat beside the bed. Interview with Registered Nurse #3 on 10/10/18 at 4:25 PM, on the 100 hallway, revealed proper fall risk interventions for Resident #87 included a floor mat on the left side of the bed. Continued interview on 10/10/18 at 4:28 PM, in the resident's room, confirmed the floor mat was not positioned in the floor next to the bed and the facility failed to implement the falls intervention for Resident #87",2020-09-01
1042,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,695,D,0,1,8DM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement oxygen therapy according to accepted professional standards for 1 Resident (#62) of 8 residents receiving oxygen of 35 residents reviewed. The findings include: Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed the resident had moderate cognitive impairment and received oxygen therapy. Medical record review of the Physician's Recapitulation Orders dated 10/1/18 to 10/31/18 revealed .02 (oxygen) up to 6 LPM (liters per minute) to try to maintain SATS (oxygen saturation) > (greater than) 88% (percent). Observation on 10/8/18 at 11:35 AM, in the resident's room, revealed an oxygen concentrator (medical device to deliver oxygen) in the resident's room. Further observation revealed the oxygen concentrator was not turned on and the oxygen tubing was on the floor. Interview and observation with Licensed Practical Nurse (LPN) #3 on 10/8/18 at 11:40 AM, in the resident's room, revealed the oxygen was to be administered continuously. LPN #3 checked the resident's oxygen saturation and the results were 94% on room air. The LPN wet a paper towel with water, wiped the oxygen tubing off, placed the tubing in the resident's nostrils, and turned the oxygen concentrator to 2 liters per minute. Interview with LPN #3 revealed .I should have went and got new tubing instead of wiping it off with a wet paper towel . Interview with the Director of Nursing on 10/11/18 at 4:14 PM, in the admission office, confirmed the facility failed to follow accepted professional standards for oxygent therapy for Resident #62.",2020-09-01
1043,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,744,D,0,1,8DM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to monitor interventions to reduce behaviors of dementia for 2 (#87 and #26) of 5 residents reviewed for dementia care of 39 sampled residents. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's care plan dated 3/14/18 revealed the resident was care planned for yelling out for help with an intervention to monitor and record behavior. Medical record review of Resident #87's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #87 had an active [DIAGNOSES REDACTED]. Medical record review of Resident #87's Medication Administration Record [REDACTED]. Multiple observations conducted daily during the annual Recertification survey 10/8/18 - 10/11/18, revealed Resident #87 frequently called out help me. Interview with Certified Nursing Assistant (CNA) #2 on 10/11/18 at 6:42 PM, at the 100 unit nurses station, revealed .it's all the time he hollers 'help me' .he hollers 'help me, help me' all night . Interview with Licensed Practical Nurse (LPN) #1 on 10/11/18 at 6:33 PM, at the 100 unit nurses station, revealed .he hollers out 'help me' it'd be an all the time thing if we charted it every time . Interview with the Director of Nursing on 10/11/18 at 7:34 PM, in the Conference Room, revealed .it would be there on the MAR; and if it's not, then it's not been documented . Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #26's Care Plan reviewed on 8/2/18 revealed .wandering will attempt to get out doors and has entered other rooms .Monitor and record behavior . Medical record review of the Medication Administration Records from 5/1/18 - 10/10/18 revealed no documentation of monitoring for wandering. Interview with the Social Services Director on 10/11/18 at 10:23 AM, at the 300 hall Nurses Station, confirmed there was no documentation of monitoring for exit seeking or wandering for Resident #26. Interview with the Director of Nursing on 10/11/18 at 5:26 PM, in the conference room, confirmed the social worker was responsible for initiating monitoring sheets. Continued interview confirmed exit seeking or wandering monitoring sheets were not implemented.",2020-09-01
1044,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,842,D,0,1,8DM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#85) of 39 sampled residents. The findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #85's current care plan dated 4/12/18 revealed the resident was care planned for wandering with interventions .Monitor and record behavior . Review of Resident #85's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. Further review of the MDS revealed the resident was coded as wandering that occurred 1 to 3 days. Review of Resident #85's Medication Administration Record [REDACTED]. Multiple observations conducted daily during the annual Recertification survey 10/8/18 - 10/11/18, revealed Resident #85 wandered daily. Interview with Certified Nursing Assistant (CNA) #1 on 10/8/18 at 1:00 PM, on the 100 unit hall, confirmed Resident #85 was wandering. Further interview with CNA #1 revealed She's usually in and out of rooms. Interview with CNA #2 on 10/11/18 at 8:04 AM, on the 100 hall, revealed She is in and out of rooms. She gets around the building. Interview with Licensed Practical Nurse (LPN) #1 on 10/11/18 at 2:35 PM, at the 100 unit nurses station, revealed Resident #85 had dementia, did not know where she was, and she wandered. Interview with LPN #2 on 10/11/18 at 2:58 PM, at the 100 unit nurses station, confirmed the monitoring sheet indicated the resident had no wandering behavior this month. Further interview with LPN #2 revealed the resident had wandered this week. Further interview revealed Maybe they are just so used to her wandering that it is normal rolling around in her house and they aren't charting it as wandering. Interview with the Director of Nursing on 10/11/18 at 5:28 PM, in the Conference Room, revealed I'd agree it is not being coded correctly; the coding means it's not being documented correctly.",2020-09-01
1046,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2018-10-11,925,D,0,1,8DM911,"Based on observation and interview, the facility failed to maintain an effective pest control program in 1 hallway of 3 hallways observed during the survey, affecting 1 resident (#7) of 39 sampled residents. The findings include: Review of facility policy, Pest Control dated 1/2015, revealed .Our facility shall maintain an effective pest control program .to ensure that the building is kept free of insects . Observation on 10/8/18 at 11:00 AM, in Resident #2's room, revealed the resident lying in bed with a fly strip ribbon hanging from the ceiling above the resident. Continued observation revealed several small dead black insects on the hanging fly strip ribbon. Interview with the Maintenance Director on 10/10/18 at 5:14 PM, in the 300 nursing station, confirmed .issues with gnats within last 3 months .Have had residents complain about gnats . Observation and interview with the Maintenance Director on 10/10/18 at 5:19 PM, outside of Resident #7's room, confirmed .I installed fly trap (fly strip ribbon in the resident's room) for gnats .Does not seem sanitary (fly strip hanging above the resident's bed) . Observation on 10/11/18 at 8:35 AM, outside of Resident #2's room, revealed the resident lying in bed with the fly trap ribbon hanging from the ceiling above the resident's bed. Continued observation revealed several small dead black insects on the hanging fly strip ribbon. Further observation revealed a Certified Nursing Assistant delivered the resident's breakfast tray and placed the tray on the bedside table. Interview with the Director of Nursing on 10/11/18 at 2:26 PM, in the conference room, confirmed the fly ribbon was not sanitary to hang in a resident's room and the facility failed to follow the pest control policy.",2020-09-01
1047,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2020-01-23,656,D,0,1,FKIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to develop an individualized care plan for [MEDICAL CONDITION] Disorder (a mood disorder) and for the special services provided resulting from Level II PASAAR (preadmission screening and resident review) recommendations for 1 resident of 31 (#118) sampled residents. The findings include: Review of the facility policy, Care Planning and Interventions, revised 7/23/2009, showed .The interdisciplinary team .develops an individualized care plan .to provide the greatest benefit to the resident .The care plan addresses, to the extent possible, resident specific interventions . Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #118's Level II PASAAR, dated 2/27/2018, showed .the (preadmission screening review) .decided that you need special services for your mental health .these special services can be provided while you are in the nursing home .(PASAAR) identified services .(Resident #118) would benefit from continued therapy services by his facility's mental health provider for support with management of symptoms, as he indicated that talking with someone helps with symptoms . Review of Resident #118's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. Review of a psychotherapy progress note, dated 12/30/2019, showed Resident #118 .is able to communicate needs, wants, and participate in basic conversation . and had a current [DIAGNOSES REDACTED]. Review of Resident #118's current comprehensive care plan, dated 1/3/2020, revealed the following: .[MEDICAL CONDITION] medications r/t (related to) anxiety, [MEDICAL CONDITION] disorder .revised 1/10/2020 . Continued review revealed, .antidepressant medication r/t (related to) depression .revised 1/10/2020 . During interview and record review on 1/23/2020, at 2:50 PM, MDS Coordinator #1 stated she was ultimately responsible for the resident's comprehensive care plan. MDS Coordinator #1 demonstrated in the electronic health record software program how care plan interventions were selected from a menu of preset options, or a new intervention could be created through a custom option. MDS Coordinator #1 confirmed the resident's care plan for [MEDICAL CONDITION] Disorder contained no custom interventions and was not individualized. Ongoing interview with MDS Coordinator #1 confirmed she completed his PASAAR documentation and was unaware of the resident's Level II recommendations that the resident was receiving at the facility.",2020-09-01
1048,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2020-01-23,657,D,0,1,FKIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to update the care plan for 2 residents (#25 and #155) of 31 residents reviewed for care planning. The findings include: Review of the facility policy titled, Care Planning and Interventions, revised [DATE], showed the interdisciplinary team was responsible to develop an individualized care plan with resident specific interventions and update the care plan as needed. Review of Resident #25's medical record showed she was admitted [DATE], following a hospital stay, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], showed the resident cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of the resident's Care Plan, dated [DATE], showed the Focus (Problem) areas was not updated to include the need for oxygen supplementation, the recent history of a rapid onset of [MEDICAL CONDITION] due to [MEDICAL CONDITIONS] and Pleural Effusion, or the [MEDICAL CONDITION] (high potassium in the bloodstream/a life threatening condition), diagnosed upon transfer to the hospital [DATE]. Review of the resident's progress notes for [DATE], showed from 1:12 AM to 4:00 PM the resident's oxygen saturation (SaO2) decreased from 92% on 2L/m oxygen (liters per minute) to 83% SaO2 on 5L/m (indicating the increase in oxygen was not helping the resident's decompensating respiratory status). During an interview on [DATE], at 4:50 PM, the Unit 3 Manager stated the resident was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION] with Hypercapnia (an excess of carbon [MEDICATION NAME] in the bloodstream), Pleural Effusion, [MEDICAL CONDITION] and [MEDICAL CONDITION]. During an interview on [DATE], at 5:15 PM, with concurrent review of Resident 25's Comprehensive Care Plan, the Unit 3 Manager stated the resident's Care Plan had not been updated to include the [DIAGNOSES REDACTED]. Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #155's comprehensive care plan, dated [DATE], revealed the resident had an Advance Directive for Cardiopulmonary Resuscitation (CPR) and Full Treatment. Medical record review of a Physician Orders for Scope of Treatment (POST/an advanced directive) dated [DATE], revealed Resident #155 had chosen Do Not Resuscitation (DNR) with limited additional interventions. Interview with the Director of Nursing on [DATE] at 5:21 PM, confirmed the comprehensive care plan had not been revised to reflect the change to a DNR status as indicated on Resident #155's POST form.",2020-09-01
1049,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2020-01-23,690,D,0,1,FKIW11,"**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 assess for removal of an indwelling urinary catheter (a tube inserted in the bladder to drain urine into a bag outside of the body) and failed to document medical justification for the use of a urinary catheter for 1 resident (#126) of 3 residents reviewed for indwelling catheter of 31 sampled residents. The findings include: Review of the facility's policy titled Urinary Incontinence and Indwelling Catheter .Management, reviewed 4/22/2019, showed .A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of that catheter as soon as possible . Review of the medical record showed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documented [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] showed Resident #126 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The resident had an indwelling urinary catheter with no documented [DIAGNOSES REDACTED]. Review of a nurse's note dated 12/22/2019 showed resident c/o (complained of) not able to urinate .inserted (indwelling urinary catheter) very concentrated urine . Review of a physician's orders [REDACTED]. Review of the care plan dated 12/30/2019 showed the resident had an indwelling urinary catheter with no documented [DIAGNOSES REDACTED]. Review of the medical record revealed no assessment by the facility for the removal of the catheter from 12/22/2019 to 1/23/2020. Observation on 1/22/2020 at 3:08 PM showed Resident #126 lying on the bed with an indwelling urinary catheter drainage bag hanging on the bed frame in a privacy cover with yellow urine noted in the tubing. During an interview on 1/23/2020 at 4:02 PM, with the Unit 2 Manager, confirmed Resident #126 was admitted to the facility without an indwelling urinary catheter, the catheter was later placed due to the resident's inability to void. The Unit 2 Manager stated she had not contacted the Physician regarding the continued use of the indwelling urinary catheter. The Unit 2 Manager stated We are going to leave it in. During an interview on 1/23/2020 at 5:30 PM, the Unit 2 Manager confirmed the Physician had not provided a [DIAGNOSES REDACTED]. During an interview on 1/23/2020 at 5:36 PM, the Director of Nursing (DON) confirmed it was her expectation for a resident to be assessed for removal of the indwelling urinary catheter as soon as possible. In summary, Resident #126 was admitted to the facility without an indwelling urinary catheter on 12/20/2019, a catheter was inserted on 12/22/2019. Medical record review revealed no documented [DIAGNOSES REDACTED]. The Unit 2 Manager stated the facility would leave Resident #126's the catheter in place. The resident had not been assessed for the removal of the catheter from 12/22/2020 to 1/23/2020.",2020-09-01
1050,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2019-01-30,689,D,0,1,OYL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interview, the facility failed to complete an investigation for a fall for 1 resident (#81) identified as high risk for falls of 5 residents reviewed for falls of 31 sampled residents. The findings include: Review of the facility policy, Falls Management, revised 12/13/2018, revealed, .Promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patient's fall indicators .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level . Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15, indicating Resident #81 was cognitively intact and required extensive assistance from 2 staff members for transfers and toileting. Medical record review of Resident #81's Falls Risk Evaluations dated 6/13/18 and 9/28/18 revealed the resident was scored 18, indicating the resident was at high risk for falls. Continued review of the 11/19/18 and 1/22/19 Fall Risk Evaluations revealed the resident was scored 20. Further review of the Fall Risk Assessment revealed .Intervention: nonskid socks, call light in reach, partial SR (side rail), therapy eval (evaluation) & tx (treatment) PT (physical therapy)/OT (occupational therapy) .6/13/18 .Intervention: Fall precautions .9/18/9 (9/18/2019) .Fall precautions 01/22/19 . Medical record review of Resident #81's physician's orders dated 1/2019, revealed .Fall precautions daily . Medical record review of the resident's current comprehensive Care Plan revealed .Onset Date .06/20/18 .Problems .Potential risk for falls/injury Due To -impaired mobility -Difficulty walking/Weakness .Provide environmental adaptations .Provide/observe use of adaptive devices .Remind resident and enforce safety awareness .Report falls to physician and responsible party .Fall Precautions . Interview with Resident #81 on 1/29/19 at 1:32 PM, in the resident's room, revealed the skilled Assistant Director of Nursing (ADON) was helping her transfer from her wheelchair (w/c) to the toilet when her feet started to slip and her knees began to give. Continued interview revealed Resident #81 told the skilled ADON she couldn't stand up this way and she went down to the ground. Further interview confirmed Resident #81 it happened sometime during Summer (YEAR), she was not injured, and a second staff came in to assist her up. Interview with the skilled ADON on 1/29/19 at 1:24 PM, in the conference room, confirmed she was helping Resident #81 transfer from the w/c to the toilet and the resident came to rest on a lower level. Continued interview confirmed the facility failed to transfer Resident #81 using a 2 person transfer, and failed to complete an investigation after a fall for Resident #81.",2020-09-01
1051,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2019-01-30,695,D,0,1,OYL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer oxygen therapy as ordered for 1 resident (#129) of 9 residents reviewed for oxygen therapy of 31 residents sampled. The findings include: Medical record review revealed Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive Care Plan dated 6/16/15 and updated 1/1/19 revealed the resident had the potential for difficulty breathing related to [MEDICAL CONDITION] with approach to administer oxygen as ordered. Continued review revealed the resident received hospice service for debility and decline due to [MEDICAL CONDITION]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #129 had the Brief Interview for Mental Status (BIMS) score of 00 indicating the interview was not completed due to severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toileting. Further review revealed the resident received oxygen therapy and hospice services. Medical record review of the physician's orders [REDACTED]. Observation of Resident #129 on 1/28/19 at 11:45 AM, in the Unit 1 Day Room, revealed the resident sitting in a wheelchair. Continued observation revealed the resident had an oxygen tank in a carry pouch attached to the wheelchair. Further observation revealed the nasal canula was on the resident. Continued observation revealed the oxygen regulator was set on 0 indicating the resident was not receiving oxygen. Interview with Licensed Practical Nurse #1 on 1/28/19 at 11:45 AM, in the Unit 1 Day Room, confirmed the oxygen regulator setting was on zero and the resident was not receiving oxygen. Continued interview confirmed the physician order [REDACTED]. Interview with the Director of Nursing on 1/29/19 at 3:45 PM, at the Unit 1 Nurses Station, confirmed the resident's oxygen had not been administered as ordered.",2020-09-01
1052,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2019-01-30,759,D,0,1,OYL911,"**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 ensure medications were administered per physician orders for 3 residents (#23, #73, and #133) of 9 residents reviewed of 36 medication opportunities observed. The findings include: Review of the facility policy,General Dose Preparation and Medication Administration with a revision date of 1/1/13 revealed .Prior to administration of medication, facility staff should take all measures required by facility policy .including but not limited to the following .Facility staff should .Verify each time a medication is administered that it is the correct medication .at the correct time .During medication administration, facility staff should take all measures required by facility policy .including, but not limited to the following .Administer medications within timeframes specified by facility policy . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's Physician Orders dated 1/2019 revealed the resident was ordered [MEDICATION NAME] (blood pressure medication) 50 mg (milligram) tablet by mouth every 8 hours at 8:00 AM, 2:00 PM, and 10:00 PM. Observation with License Practical Nurse (LPN) #2 on 1/28/19 at 12:35 PM, in Resident #23's room, revealed LPN #2 administered the 2:00 PM scheduled dose of [MEDICATION NAME] 50 mg tablet to the resident. Continued observation revealed the LPN had administered the resident's medication 1 hour and 25 minutes prior to the scheduled medication administration time. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #73's Physician Orders dated 1/2019 revealed the resident was ordered [MEDICATION NAME] (narcotic pain medication) 5 mg [MEDICATION NAME] (pain medication) 325 mg tablet by mouth 3 times a day at 9:00 AM, 2:00 PM, and 10:00 PM. Continued review revealed Resident #73 was ordered [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 500 mg by mouth 2 times a day at 9:00 AM and 6:00 PM. Observation with LPN #2 on 1/28/19 at 12:12 PM, in Resident #73's room, revealed LPN #2 administered the 2:00 PM schedule dose of [MEDICATION NAME] 5 mg [MEDICATION NAME] 325 mg tablet to the resident. Continued observation revealed LPN #2 had administered Resident #73's [MEDICATION NAME] 1 hour and 48 minutes before the scheduled medication administration time. Observation with LPN #2 on 1/28/19 at 4:21 PM, in Resident #73's room, revealed LPN #2 administered the 6:00 PM scheduled dose of [MEDICATION NAME] 500 mg to resident #73. Continued observation revealed the LPN had administered Resident #73's [MEDICATION NAME] 1 hour and 39 minutes before the scheduled medication administration time. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #133's Physician Orders dated 1/2019 revealed the resident was ordered [MEDICATION NAME] (a muscle relaxant medication) 4 mg tablet one 1/2 tablet by mouth 3 times a day at 8:00 AM, 2:00 PM, and 10:00 PM. Observation with LPN #2 on 1/28/19 at 12:19 PM, in Resident #133's room, revealed LPN #2 administered the 2:00 PM scheduled dose of [MEDICATION NAME] 4 mg 1/2 tablet. Continued observation revealed the LPN had administered the resident's medication 1 hour and 41 minutes before the scheduled medication administration time. Interview with the Director of Nursing on 1/30/19 at 4:00 PM, in the conference room, confirmed the facility failed to administrator Residents #23, #73, and #133's medications at the scheduled times and failed to follow physician orders for administration. Telephone interview with the Medical Director on 1/30/19 at 4:40 PM, confirmed the Medical Director expected the facility to ensure nurses follow physician orders and administer medications at the scheduled times.",2020-09-01
1054,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2018-02-22,677,D,0,1,T9QV11,"**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 provide fingernail care for 2 residents (#68, #134) of 65 residents reviewed. The findings included: Review of the facility's Fingernail Care Policy (undated) revealed .Fingernails can be partially cleaned during hand washing and bath care .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidently scratching and injuring his/her skin . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) revealed Resident #68 had severe cognitive impairment, required extensive assistance of 1 staff for personal hygiene and extensive assistance of 2 staff for bathing. Medical record review of Resident #68's care plan revised on 12/4/17 revealed .Nursing staff to provide ADL (Activities of Daily Living) care as needed to ensure daily needs are met . Observation and interview with Resident #68 on 2/21/18 at 10:30 AM, in the day room revealed the resident had 10 long (approximately 1/2 inch), fingernails, with dark debris under the fingernail tips. Interview with the resident revealed he did not like his fingernails that long and confirmed they were soiled, also indicated he could not cut or clean his fingernails. Observation and interview with Licensed Practical Nurse (LPN) #1 on 2/21/18 at 10:35 AM, in the day room revealed the resident had 10 long fingernails soiled with dark debris under the finger nail tips. Interview confirmed the resident's fingernails required cleaning and to be trimmed. Medical record review revealed Resident #134 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE] revealed the resident had mild cognitive impairment, required extensive assistance of 2 staff for personal hygiene, and total assistance of 2 staff for bathing. Medical record review of Resident #134's care plan revealed .Provide the amount of assistance/supervision that is needed . Observation and interview with Resident #134 on 2/21/18 at 9:15 AM, in the resident's room, revealed all of the resident's 10 fingernails were approximately 1/2 inch long and soiled with dark debris under the fingernail tips, and 3 fingernails were jagged. Interview with Resident #134 revealed he did not like his fingernails that long. Observation and interview with LPN #1 on 2/21/18 at 9:21 AM, in Resident #134's room revealed all 10 fingernails were long and soiled with dark debris under the fingernail tips, and 3 were jagged. Continued interview confirmed the resident's fingernails required cleaning and trimming.",2020-09-01
1055,"HERITAGE CENTER, THE",445215,1026 MCFARLAND STREET,MORRISTOWN,TN,37814,2018-02-22,761,D,0,1,T9QV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview the facility failed to ensure all scheduled drugs were kept under a double lock system in 1 of 3 medication rooms. The findings included: Review of the facility policy .Medication Storage . dated 6/21/06 revealed .All scheduled drugs must be stored in a cabinet of substantial construction under a double lock system . Observation with the Assistant Director of Nursing (ADON) on 2/22/18 at 9:15 AM, in the 300/400 hall medication room, revealed an unlocked cabinet in the medication room. Continued observation revealed the following medications inside the cabinet: [MEDICATION NAME] (medication for anxiety) 0.5 mg (milligram) total of 23 pills, [MEDICATION NAME] (medication for pain) 10 mg/300 mg total of 13 pills, and [MEDICATION NAME] (medication for pain) 15 mg total of 120 pills. Interview with the ADON on 2/22/18 at 9:30 AM, in the medication room, confirmed the medications are to be under a double lock and the facility policy for scheduled drug storage was not followed.",2020-09-01
1057,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-06-04,609,D,1,0,IKUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interviews, the facility failed to follow their abuse policy for reporting allegations of abuse for 1 Resident (#1), and failed to report 2 allegations of abuse within federally required time frame for 1 Resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility abuse policy Abuse Prevention Policy & Procedure, revised 10/1/17, revealed .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator and Director of Nursing . All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 6/4/19 at 7:50 AM, in her room, revealed the resident was lying in bed, she was awake and alert. Continued observation revealed no anxious or fearful behaviors were identified. Interview with the Social Service Director (SSD) on 6/4/19 at 9:45 AM, in the conference room, revealed she (Resident #1) went to the doctor on 4/29/19, and during that visit she reported to the doctor she had been raped. The Physician's Social Worker called me and she said she had to follow up on the concerns .(Resident #1) had reported to the doctor, while the resident was still at the doctor's office. She said she had been raped at the facility. I told her she had a care plan of making sexual allegations that had been unsubstantiated regarding male staff. I told her in the past if a male walked by her room she would yell out that they had raped her, and I know what you did, you raped me. I told the Director of Nursing (DON) as soon as I got off the phone that she was at the doctor's office making sexual allegations. Continued interview revealed she has been making these allegations for some time and is care planned for sexual inappropriate behavior. On 4/5/19 she was calling from her room at the Maintenance Assistant stating he was the one who raped her. As far as I know 4/5/19 was the first time she had mentioned anything about rape in the facility. Interview with the DON on 6/4/19 at 10:40 AM, in the conference room, revealed I remember the SSD telling me the resident was at the doctor's office and had made sexual allegations. In my mind she was reporting the resident was stating the same things she says here, and the SSD didn't say anything about .(Resident #1) reporting she had been raped at the facility. We did not report the allegation, because I didn't take it as she was saying anything new, she had reported she had been raped in the past. I didn't know at that point she was making the allegation she had been raped in the facility. Today is my first knowledge of the resident stating she had been raped in the facility. Continued interview revealed I don't recall being informed she had yelled at the Maintenance Assistance from her room that he was the one who raped her, so no we did not report the allegation. Interview with the Administrator on 6/4/19 at 12:30 PM, in the conference room, revealed the report I received is the Maintenance Assistant was walking down the hall and she yelled out to him, 'you did it, you did it' which is a lot different than accusing him of rape. Continued interview revealed, I am unaware of her reporting during her doctor's appointment on 4/29/19, that she was raped in the facility Interview with the Maintenance Assistance on 6/4/19 at 12:43 PM, in the conference room revealed, I was walking down the hall and she yelled at me from her room. I didn't know what she said so I went back to her door way and asked what she had said. She said it is a good thing you admitted it, and I said what and she said admitted to raping me. I didn't say anything I just walked away and told . (SSD) and .(Admissions Coordinator) was in the office when I reported it. Continued interview revealed I didn't report it to the Administrator because I reported it to .(SSD). Interview with the Administrator on 6/4/19, at 3:01 PM, in the conference room, confirmed the facility failed to follow their policy for reporting 2 allegations of abuse for 1 Resident (#1) occurring on 4/5/19 and on 4/29/19. Continued interview confirmed the facility failed to report the allegations of abuse to the State Agency as required.",2020-09-01
1058,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-06-04,610,D,1,0,IKUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation and interviews the facility failed to follow their abuse policy for investigation of 2 allegations of abuse for 1 resident (#1), and failed to investigate 2 allegation of abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility abuse policy Abuse Prevention Policy & Procedure, revised 10/1/17, revealed .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator and Director of Nursing .The investigation protocol must be implemented .All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 6/4/19 at 7:50 AM, in her room, revealed the resident was lying in bed, she was awake and alert. Continued observation revealed no anxious or fearful behaviors were identified. Interview with Resident #1's daughter, on 6/4/19 at 9:25 AM, via telephone, revealed we went to her doctor in Murfreesboro on 4/29/19, during that visit she reported to them she had been raped. She said there were 300 women being raped. She said they were making purple stuff and she thought it was like ecstasy but you could buy it at .(popular chain store.) I didn't think she was reporting anything new. Continued interview revealed she had not reported it to the facility. Interview with the Social Service Director (SSD) on 6/4/19 at 9:45 AM, in the conference room, revealed she went to the doctor on 4/29/19, and during that visit she reported to the doctor she had been raped. The Physician's Social Worker called me, said she had to follow up on the concerns .(Resident #1) had reported to the doctor, while the resident was still at the doctor's office. She had said she had been raped at the facility. I told her she had a care plan of making sexual allegations that had been unsubstantiated regarding male staff. I told her in the past if a male walked by her room she would yell out that they had raped her, I know what you did, you raped me. Continued interview revealed she has been making these allegations for some time and is care planned for sexual inappropriate behavior. I reported this allegation to Director of Nursing (DON), immediately after I got off the phone. I told her she was making sexual allegations at the doctor's office. On 4/5/19 she was calling from her room at the Maintenance Assistant stating he was the one who raped her. As far as I know that was the first time she had mentioned anything about rape in the facility. Interview with the DON on 6/4/19 at 10:40 AM, in the conference room, revealed I remember the SSD telling me the resident was at the doctor's office and had made sexual allegations. In my mind she was reporting the resident was stating the same things she says here, and the SSD didn't say anything about .(Resident #1) reporting she had been raped at the facility. There was no investigation of that allegation, because I didn't take it as she was saying anything new, and she had reported she had been raped in the past. I didn't know at that point she was making the allegation she had been raped in the facility. Today is my first knowledge of the resident stating she had been raped in the facility. Continued interview revealed I don't recall being informed she had yelled at the Maintenance Assistant from her room that he was the one who raped her, so no an investigation was not done. Interview with the Maintenance Assistant on 6/4/19 at 12:43 PM, in the conference room revealed, I was walking down the hall and she yelled at me from her room. I didn't know what she said so I went back to her doorway and asked what she had said. She said it is a good thing you admitted it, and I said what? And she said, admitted to raping me. I didn't say anything; I just walked away, and told . (SSD) and .(Admissions Coordinator) was in the office when I reported it. Continued interview revealed I wasn't' placed on suspension, as far as I know there was not investigation. I didn't report it to the Administrator because I reported it to .(SSD) Continued interview revealed, I don't recall ever being in her room before she made that allegation. I've been in there one time since then to fix the plug on her bed but she was not in there. Interview with the Administrator on 6/4/19, at 3:01 PM, in the conference room, confirmed she was unaware Resident #1 had reported on two occasions an allegation of sexual abuse occurring in the facility. Continued interview confirmed the facility failed to follow their policy for investigating 2 allegations of abuse for 1 Resident (#1) occurring on 4/5/19 and on 4/29/19.",2020-09-01
1059,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2018-06-18,609,D,1,0,3K8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interview the facility failed to follow their abuse policy for reporting allegations of abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Policy & Procedure dated 10/1/11 revealed .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, so that the resident's needs can be attended to immediately and investigation can be undertaken promptly .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Review of the facility investigation revealed .Date of Occurrence 6/2/18 Time of Occurrence 6:00 PM .On 6/3/18 at 7:15 PM, Director of Nursing (DON) made aware of allegation of physical abuse . Interview with Certified Nurse Aide (CNA) #1 on 6/13/18 at 10:15 AM, in the conference room, revealed (CNA #2) asked me to help her with (Resident #1) she needed changing. I was holding her hands because if you don't she will scratch you or herself, (CNA #2) was trying to get her shirt off, and (Resident #1) was restless, she moves around when you are trying to change her, and she spits all the time. She was making the noise like she does when she is going to spit, and that's when (CNA #2) popped her in the mouth. I didn't report the incident before I left the facility. I knew I should have told someone then, but I didn't. I told the charge nurse the next day what had happened. Further interview confirmed CNA #1 was unable to recall when he had reported the allegation of abuse to the charge nurse. I can't remember for sure when I told her. Interview with Registered Nurse (RN) #1 on 6/14/18 at 11:10 AM, via telephone, confirmed CNA #1 had reported the allegation of abuse to her between 4:00 PM and 5:00 PM, on 6/3/18. He reported it happened at the end of the shift on 6/2/18 .I explained he was supposed to report it immediately, and remove the patient from the situation. Continued interview confirmed she had notified the administrative staff on call, but had not called him until approximately 6:30 PM, on 6/3/18, when she was leaving the facility . Interview with the DON on 6/13/18 at 3:40 PM, in the conference room, confirmed the incident had occurred on 6/2/18 at approximately 6:00 PM, and (CNA #1) had not reported it until the following night between 4:00 and 5:00 PM to the Nurse Supervisor (RN #1). RN #1 did not report the allegation of abuse to administration until approximately 7:00 PM on 6/3/18. Further interview confirmed the facility failed to follow their abuse policy for reporting abuse, and failed to report an allegation of abuse to the State within the federally required time frame.",2020-09-01
1060,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2017-06-21,441,D,0,1,3CE011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly store 2 [MEDICATION NAME] safety needles and failed to properly maintain equipment in a sanitary manner for 1 of 3 Soiled Utility Rooms. The findings included: Observation of the 300/500 hall Soiled Utility Room during the Initial Tour on 6/19/17 at 9:20 AM, revealed 2 packaged [MEDICATION NAME] safety needles in the right side of a 2-compartment sink. Continued observation revealed the 2-compartment sink had dried debris in both compartments of the sink. Further observation revealed a bowl with dirty water stored in the right side of the sink. Interview with Licensed Practical Nurse (LPN) #2 on 6/19/17 at 9:25 AM in the 300/500 hall Soiled Utility Room confirmed the facility failed to properly dispose of the 2 packaged [MEDICATION NAME] safety needles. LPN #2 also confirmed the sink was dirty with dried debris in both compartments of the sink and the bowl contained dirty water. Further interview confirmed the facility failed to properly maintain the 2-compartment sink in a sanitary manner. Observation of the 300/500 hall Soiled Utility Room on 6/19/17 at 2:30 PM revealed the 2-compartment sink was dirty with dried debris in both compartments of the sink. Observation of the 300/500 hall Soiled Utility Room on 6/20/17 at 2:00 PM, with the Administrator present revealed the 2-compartment sink was dirty with dried debris in both compartments of the sink. Interview with the Administrator on 6/20/17 at 2:00 PM in the 300/500 hall Soiled Utility Room confirmed the facility failed to properly maintain the equipment in a sanitary manner.",2020-09-01
1061,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-07-30,609,D,1,0,0I8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interviews, the facility failed report an allegation of abuse timely for 1 Resident (#1) of 5 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Policy & Procedure revised 2/26/18 revealed .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency .per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Review of a facility investigation dated 7/18/19 revealed a Hospitality Aide (HA #1) reported on 7/18/19 to the Staff Development Coordinator (SDC) that on 7/14/19 a Certified Nursing Assistant (CNA #1) cursed and verbally threatened Resident #1. Continued review revealed Resident #1 denied any staff member was rude to him or threatened him. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. Telephone interview with CNA #1 on 7/30/19 at 8:55 AM revealed .I never cursed him (Resident #1) .threatened him .or did anything or say anything out of the way to him .I just don't know why she (HA #1) would say something like that . Observation of Resident #1 on 7/30/19 at 9:30 AM, in the activities room, revealed the resident seated at a table actively participating in an activity. Further observation revealed no signs of anxiety or fearful behaviors. Interview with the SDC on 7/30/19 at 10:15 AM, in the conference room, revealed .she (HA #1) came in my office on (7/18/19) in the afternoon about 1:30 PM, she said I need to talk to in private .she said I was working with a CNA and she asked me to help her with a resident .they went into (Resident #1's) room .(CNA #1) said 'I can't stand this (f------) place' .(HA #1) said (CNA #1) roughly turned the resident over startling him and the resident grabbed (HA #1's) scrub top and the grab bar with his other hand .said (CNA #1) told the resident 'if he didn't let go of the bar (CNA #1) was going to punch him in the (f------) face.' (HA #1) stated that (CNA #1) always states she hates her job here .and (CNA #1) hates the residents .I asked (HA #1) why she hadn't reported it and she said she was scared because she had to work with (CNA #1) a lot . Interview with the Human Resource Director on 7/30/19 at 10:55 AM, in her office, revealed .we go over abuse .the different types of abuse .what to do including reporting (abuse) .(Hospitality Aide #1) received her abuse education on 6/10/19 . Telephone interview with Hospitality Aide #1 on 7/30/19 at 11:55 AM revealed .it (incident) happened on (7/14/19) .(CNA #1) asked me to help change (Resident #1) . when we turned (the resident) he must have thought he was falling because he grabbed the bar and my shirt .(CNA #1) told him to 'let go of the f---ing rail' or she 'was going to punch him in the f---ing face.' I didn't report it .supposed to report abuse immediately . Interview with the Administrator on 7/30/19 at 12:40 PM, in the conference room, revealed HA #1 stated the allegation occurred on 7/14/19. Further interview confirmed the incident was not reported until 7/18/19 (4 days after the alleged incident). Continued interview confirmed the facility failed to follow their abuse policy for reporting an allegation of abuse to the State Survey Agency within 2 hours.",2020-09-01
1066,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2018-08-22,812,D,0,1,IWHQ11,"Based on facility policy review, observation and interview, the facility failed to ensure 5 of 5 glasses of whole milk were held at the proper holding temperature on the tray line, potentially affecting 1 of 6 halls. The findings included: Review of the facility policy Food Temperatures revised 2/08/18 revealed .Acceptable serving temperatures* are .Milk .41 but preferably .35-41 degrees F . Observation of the Dietary Manager on 8/20/18 at 12:10 PM taking temperatures on the kitchen serving tray line revealed the first glass of whole milk was 47 degrees. The second glass of whole milk was 44 degrees. The third glass of whole milk was 49 degrees. The fourth glass of whole milk was 51 degrees. The fifth glass of whole milk was 48 degrees. Interview with the Dietary Manager on 8/20/18 at 12:12 PM, in the kitchen, confirmed the glasses of whole milk .were going to go out on the line . Further interview confirmed the glasses of whole milk were above the proper holding temperature .I'd love for it to be 41 degrees or below .",2020-09-01
1067,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-09-25,600,D,1,0,X6BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to prevent abuse for 2 residents (#4 and #5) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed, The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents .This facility shall not condone any acts of resident .physical and/or mental abuse .RESIDENT-TO-RESIDENT ABUSE POLICY .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical .abuse from other residents . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Care Plan dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Quarterly MDS dated [DATE] revealed the Resident had a BIMS of 15 indicating the resident was cognitively intact. Medical record review of Resident #5's Care Plan dated 9/6/19 (active) revealed .Resident exhibits physically aggressive and socially inappropriate behaviors .attempting to hit, yelling and cursing . Review of facility documentation dated 9/17/19 revealed .(Resident #5) came to doorway and nurse (nurse name) saw . his shirt was ripped and asked what happened .(Resident #5) states that another resident (Resident #4) came into his room and pulled his cover of (off) and told him to get up and out of his bed .(Resident #4) the (then) pulled on his clothes and ripped his shirt when he didn't get up .(Resident #5) states he hit the other resident in the privates and he left the room . Interview with License Practical Nurse (LPN) #1 on 9/24/19 at 2:55 PM, in the conference room, confirmed LPN #1 had interviewed both Residents #4 and #5 following the physical altercation on 9/17/19. Continued interview confirmed resident to resident abuse occurred. Interview with LPN #2 on 9/24/19 at 3:07 PM, in the conference room, confirmed she was the first nurse on the scene after the incident. Continued interview confirmed she noted Resident #5 had a ripped shirt. Further interview confirmed the physical altercation occurred between Residents #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with Resident #5 on 9/24/19 at 3:21 PM, in the resident's room, confirmed . (Resident #4) tried to get me out of bed .Ripped my shirt I hit Resident #5 . Interview with the Director of Nursing (DON) on 9/24/19 at 3:39 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with the Administrator (Abuse Coordinator) on 9/24/19 at 3:57 PM, in the conference room, confirmed the facility failed to prevent abuse for Residents #4 and #5.",2020-09-01
1068,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-09-25,745,D,1,0,X6BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, Social Service Job Description review, medical record review, and interview the facility failed to have Social Services follow up with 2 residents (#4 and #5) of 5 residents reviewed for abuse following a physical altercation between Residents #4 and #5. The findings include: Review of the facility's abuse policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed .REPORTING/INVESTIGATION/RESPONSE POLICY .Facility Social Worker is to provide counseling and support to the resident and possibly the family involved .The counseling is to be provided as long as necessary .the psychosocial intervention is to be documented in the resident's clinical record . Review of the Social Service Job description, Social Services, revised 6/2006 revealed General Purpose .Identify and provide for each resident's social, emotional and psychological needs .Essential Job Functions .Provide timely and accurate completion of Social Services .Progress Notes as well as Social Service Assessment .and other forms as required by the Administrator in order to comply with federal and state regulations and facility policies and procedures .Maintain progress notes for each resident as required by company policy and state and federal regulations .Progress notes must reflect progress made regarding problems identified in the Plan of Care . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Care Plan dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Medical record review revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Quarterly MDS dated [DATE] revealed the Resident had a BIMS of 15 indicating the resident was cognitively intact. Medical record review of Resident #5's Care Plan dated 9/6/19 (active) revealed .Resident exhibits physically aggressive and socially inappropriate behaviors .attempting to hit, yelling and cursing . Continued review revealed the residents care plan was updated on 9/17/19 and a new intervention was initiated. Further review revealed .9/17/19 RESIDENT TO RESIDENT CONTACT .RESIDENT EDUCATED ON ASKING FOR HELP FROM STAFF IF HAVING DIFFICULTY WITH ANOTHER RESIDENT INSTEAD OF ENGAGING IN PHYSICAL CONTACT . Review of facility documentation dated 9/17/19 revealed .(Resident #5) came to doorway and nurse (nurse name) saw . his shirt was ripped and asked what happened .(Resident #5) states that another resident (Resident #4) came into his room and pulled his cover of (off) and told him to get up and out of his bed .(Resident #4) the (then) pulled on his clothes and ripped his shirt when he didn't get up .(Resident #5) states he hit the other resident in the privates and he left the room . Medical record review of Resident #4's General Notes revealed no Social Service documentation from 9/17/18-9/24/19 following a physical altercation related to abuse which occurred on 9/17/19 between Residents #4 and #5. Interview with the Social Worker (SW) on 9/24/19 at 11:18 AM, in the conference room, confirmed the SW failed to conduct any follow up services with Resident #4 and #5 after an incident of resident to resident abuse on 9/17/19. Continued interview confirmed the SW was unaware she was responsible for providing counseling and support to Resident #4 and #5 after any allegation or suspicion of resident abuse occurred. Further interview confirmed .I didn't know then but I know now . Interview with the Director of Nursing (DON) on 9/24/19 at 2:37 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Further interview confirmed physical abuse had occurred between Residents #4 and #5. Continued interview confirmed the facility failed to have Social Services follow up with Residents #4 and #5 as required by the facility's policy. Further interview confirmed Social Services failed to provide counseling and support to Residents #4 and #5 after the abuse allegation.",2020-09-01
1069,SIGNATURE HEALTHCARE OF ELIZABETHON REHAB & WELLNE,445217,1200 SPRUCE LANE,ELIZABETHTON,TN,37643,2019-10-02,600,D,1,1,IXRK11,"**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 prevent abuse for 1 resident #22 of 8 residents reviewed for abuse of 29 sampled residents The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed It is the organization's intention to prevent the occurrence of abuse .Abuse .includes physical abuse .willful .means non-accidental .Willful as used in the definition of abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5 indicated the resident had severe cognitive impairment and required extensive assistance for bed mobility, toileting, transfer, dressing and toileting. Medical record review revealed Resident #173 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #173's Significant Change MDS dated [DATE] revealed the resident had a BIMS score of 7, indicated the resident had severe cognitive impairment, coded with hallucinations and delusions, required extensive assistance for dressing, limited assistance for toileting and hygiene and supervision for locomotion, bed mobility, transfer and locomotion. Medical record review of Resident #173's care plan dated 2/12/19 revealed .Resident is a threat to self and/others .history of physical and verbal abuse . rejection of care, urinates in inappropriate places R/T (related to) Dementia, Depression, history of [MEDICAL CONDITION] .Goal .Resident will not harm self or others . Medical record review of Resident #173's nurse's note dated 7/4/19, revealed at 9:50 PM, Certified Nursing Assistant (CNA) was summoned to the room by resident (#173), who told him that he had beat up his roommate (#22). Roommate (Resident #22) said resident had hit him twice in the face and roommate's urinary catheter was pulled out. No injuries were noted to resident. Residents were separated and monitored. Contacted Director of Nursing (DON), MD (Medical Doctor), new orders to send out for behavioral modification and psych evaluation. Contacted both families. Resident had on roommates's shoes and refused to remove them, saying they were his. Resident left facility via EMS (Emergency Medical Services) at 11:18 PM. Medical record review of Resident #173's Psychiatric note dated 7/15/19, revealed the resident had continued inappropriate and bizarre behavior and had to move his roommate (Resident #22) out because of the resident's behavioral disturbances. Interview with CNA #1 on 10/1/19 at 2:20 PM, in the conference room, confirmed she was working as a CNA on the 200 hall on 7/3/19. Continued interview confirmed another CNA called for her and she went into the room while the other CNA separated Resident 173 and Resident #22. Further interview confirmed staff took Resident #173 out of the room and staff cleaned up Resident #22 because his catheter had been pulled out and and there was blood on Resident #22. Further interview confirmed Resident #22 told the CNA that Resident #173 had hit him in the face. Continued interview confirmed she was not aware of any other incidents of aggression. Further interview confirmed it was at the end of her shift and she left shortly after the incident. Interview with CNA #2 on 10/1/19 at 3:10 PM by phone, revealed he worked from 6 PM-10 PM on the day of the incident (7/3/19). Further interview confirmed he was passing ice and went in to resident's room and the lights were off, he turned the lights on and saw Resident #173 standing by Resident #22 in his bed. Further interview confirmed blood was on Resident #22's sheet and the urinary catheter had been removed from Resident #22. Continued interview confirmed Resident #173 stated that he had beat the hell out of him (resident #22). Further interview confirmed Resident #22 stated to the CNA that Resident #173 had hit him. Continued interview confirmed Resident #22 was checked for any injuries and no marks or injuries were found. Further interview confirmed the residents were separated he was unsure what room the residents were sent to. Further interview confirmed he was not aware of either residents having aggressive behavior prior to this event. Review of a statement by the DON dated 10/2/19 revealed .This nurse spoke with resident (#173) the next day on 7/4/19 about incident the night before. He had told me that his roommate left because he beat him up & there was blood all over the place but didn't remember much about the night except he went to jail & they released him . I had also spoke to the other resident (Resident #22)who stated to just forget it ever happened .I spoke with (Resident #173)'s daughter on 7/5/19 from home in regards to his behaviors & explained he may be more appropriate in a behavior unit if his behaviors continued with refusing care, etc .",2020-09-01
1070,SIGNATURE HEALTHCARE OF ELIZABETHON REHAB & WELLNE,445217,1200 SPRUCE LANE,ELIZABETHTON,TN,37643,2018-11-07,558,D,1,1,3QH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to accommodate the request to transfer to bed timely for 1 resident (#49) of 3 residents reviewed for activities of daily living needs of 28 residents reviewed. The findings include: Review of the facility's policy Answering Call Light, undated, revealed .If you have promised the resident you will return with the item or information, do so promptly . Medical record review revealed Resident #49 was admitted to the facility on [DATE] and discharged home on[DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making, and required extensive assistance of 2 persons with transfers. Review of facility documentation revealed on 10/18/18 at approximately 6:15 PM the resident had requested Certified Nursing Assistant (CNA) #1's assistance to transfer to the bed. Continued review of facility documentation revealed CNA #1 told the resident she would return to assist the resident to transfer to bed after picking up dinner trays from the residents on the hall. Continued review of facility documentation revealed CNA #1 forgot to return to Resident #49's room to assist her to bed and when CNA #1 returned to the resident's room to put her to bed the resident was mad. Interview with the Director of Nursing on 11/5/18 at 1:45 PM, in the conference room, revealed it was approximately 45 minutes to an hour before the resident's request/need for transfer to the bed was completed. Further interview confirmed the resident's need was not met in a timely manner. Telephone interview with CNA #1 on 11/6/18 at 4:05 PM, revealed Resident #49 had requested assistance to transfer to bed on 10/18/18 at approximately 6:15 PM, and CNA #1 told the resident she would return after picking up dinner trays. Continued interview revealed CNA #1 had forgotten about the resident's request for assistance to bed and confirmed it was approximately an hour before CNA #1 returned to the resident's room to assist the resident to bed.",2020-09-01
1071,SIGNATURE HEALTHCARE OF ELIZABETHON REHAB & WELLNE,445217,1200 SPRUCE LANE,ELIZABETHTON,TN,37643,2018-11-07,641,D,0,1,3QH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) for 1 resident (#115) of 3 residents reviewed for hospice services of 28 residents reviewed. The findings include: Medical record review revealed Resident #115 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Medical record review of the Hospice Certification of Terminal Illness form revealed the start of care date for hospice services was 8/6/18. Medical record review of a significant change of status Minimum Data Set ((MDS) dated [DATE] did not reflect the resident was receiving hospice services. Interview with Licensed Practical Nurse (LPN) #1 on 11/7/18 at 11:00 AM, in the MDS office, confirmed the MDS dated [DATE] did not reflect the resident was receiving hospice services and was not accurate.",2020-09-01
1072,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2019-05-02,609,D,1,0,4NVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report allegations of sexual abuse and neglect within 2 hours for 2 of 6 (Resident #1 and #6) sampled residents reviewed. The findings include: Review of the facility's Abuse Prevention Policy and Procedure documented, .Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .Report to State Health Department and other regulatory agencies immediately .Administrator Guidance for Investigations .The initial report to the State Agency may be made by phone, fax, or electronic submission to meet the 2 hour reporting requirement . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 scored 6 on the Brief Interview of Mental Status, which indicated severely impaired cognition for decision making tasks. Review of the Resident Incident Report dated 4/22/19 at 8:35 PM documented, .IT WAS REPORTED TO CHARGE NURSE THAT RESIDENT WAS SEEN BY CNA (Certified Nursing Assistant) IN ROOM INAPPROPRIATELY TOUCHING ANOTHER RESIDENT GENITALS THAT WERE EXPOSED TO HIM . Review of the Nurse's Note dated 4/23/19 documented, .Late entry for 4/22/19 8:35pm. Cna reported resident 516b in bed propped up on right side holding resident 508a (Resident #1) penis in hand .Supervisor and DON (Director of Nursing) were immediately notified. DON immediately notified Administrator . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 4/22/19 at 11:38 PM. Interview with Licensed Practical Nurse (LPN) #1 on 5/2/19 at 2:08 PM, revealed LPN #1 checked her cell phone to determine the time the DON was notified. LPN #1 stated, .I called and talked to (Named DON) at 8:35 (PM). Interview with the Administrator on 5/2/19 at 3:12 PM, in the Conference Room, the Administrator stated, I know its 2 hours, but that's a lot to do. I knew at 9:01 (PM). When the Administrator was asked if the allegation was reported within 2 hours, she stated, No. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Concern/Comment Report dated 4/30/19 documented .RR (Resident Representative) states that resident was found in floor when he visited .RR feels that staff was neglectful .DATE/TIME OF INITIAL CONTACT WITH CONCERNED PARTY 4/23/19 1:35PM . Interview with the Social Worker (SW) on 5/2/19 at 11:30 AM, in the Conference Room, the SW confirmed she had talked with Resident #6's son and filled out the Concern/Comment report dated 4/23/19 at 1:35 PM. When asked what time the allegation of neglect was reported, the SW looked at the fax confirmation sheet and stated, .1644 (4:44 PM) (3 hours and 9 minutes after the staff became knowledgeable of the neglect allegation) .I had to wait on the Administrator to approve what I had written and get back to me. She had to proofread it first. It was a little longer than 2 hours. Interview with the DON on 5/2/19 at 1:55 PM, in the Conference Room, the DON confirmed she was knowledgeable of the allegation of neglect by Resident #6's son at the time of the call at 1:35 PM or right after. The DON confirmed attempts were made to contact the Administrator, but were unable to reach by phone until approximately 3:43 PM.",2020-09-01
1073,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2018-11-08,684,D,0,1,X2CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, medical record review, and interview, the facility failed to ensure each resident was repositioned to promote comfort and provide pressure relief for 1 (Resident #22) of 4 residents reviewed for positioning. The findings include: 1. The facility's Repositioning policy documented, .A turning /repositioning program includes a continuous consistent program for changing the resident's position and realigning the body .Place the resident in a comfortable position in accordance with the resident's individualized care plan .The following information should be recorded in the resident's medical record .The position in which the resident was placed .The name and title of individual who gave the care .signature and title of the person recording the data . 2. Medical record review revealed Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimal Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) 2 indicating severe cognitive impairment, extensive assistance with bed mobility. Observations of Resident #22 on 11/5/18 at 9:35 AM, in the resident's room revealed, the resident was lying in bed on her right side. Observations of Resident #22 on 11/6/18 at 7:43 AM, 11:40 AM, 12:04 PM, 1:09 PM, and 4:09 PM, in the resident's room revealed, the resident was lying in bed asleep on her right side with her head and neck in a bent position to the right. Observations of Resident #22 on 11/8/18 at 7:44 AM, in the resident's room revealed, the resident was lying in bed on the right side with head bent to the right. Interview with Licensed Practical Nurse (LPN) #1 on 11/6/18 at 4:25 PM, in the 800 Hall, LPN #1 was asked if Resident #22 was totally dependent on staff for turning and positioning. LPN #1 stated, Yes, she is . Interview with LPN #2, on 11/08/18 at 9:37 AM, in Resident #22's room, the LPN #2 was asked do you expect the resident to have support under her head. LPN #2 stated, .Yes I would . Interview with LPN #2 on 11/8/18 at 1:05 PM, at the 800 hall desk, LPN #2 confirmed that the documentation was incomplete for positioning.",2020-09-01
1075,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2018-11-08,880,D,0,1,X2CD11,"Based on policy review, observation, and interview the facility failed to ensure practices to prevent the development and transmission of infection when 1 of 32 staff members (Certified Nurse Assistant (CNA) #1) handled food with their bare hands during 2 of 2 (11/5/18 and 11/6/18) meal observations. The findings include: The facility's Assistance with Meals (undated) policy documented, .3. All employees .will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Observations in the 600 hall dining room on 11/5/18 beginning at 12:14 PM, CNA #1 removed the bread from a plastic sandwich bag and placed it on a resident plate, picked up a piece of chicken off of a resident's plate, and pulled a piece of chicken apart with her bare hands. Observations in the 600 hall dining room on 11/6/18 beginning at 7:47 AM, CNA #1 dropped a paper package into a resident's cup of coffee and used her bare hands to remove the package from the cup. Interview with the assistant Director of Nursing (ADON) on11/8/18 at 9:40 AM, in the 800 hall, the ADON confirmed that staff should not touch food with their bare hands.",2020-09-01
1076,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2017-12-05,550,D,0,1,7XFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to preserve the dignity of 1 of 1 (Resident #80) sampled residents observed for [MEDICAL CONDITION] care by failing to provide privacy during care and for 1 of 12 (Resident #145) residents observed during assisted dining by failing to assist the resident timely. The findings included: 1. The facility's Resident's Rights policy documented, .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident #80's room on 12/6/17 at 9:32 AM revealed Resident #80 was receiving [MEDICAL CONDITION] care from the Respiratory Supervisor without the privacy curtain pulled or the door to the hallway closed. Interview with the Respiratory Supervisor on 12/6/17 at 9:40 AM in the sub acute hallway, the Respiratory Supervisor was asked if the Resident's privacy curtain should have been pulled and the door to the hallway closed while performing [MEDICAL CONDITION] care. The Respiratory Supervisor stated, Yes . Interview with the Director of Nursing (DON) on 12/7/17 at 5:20 PM in the conference room, the DON was asked if the privacy curtain should be pulled and the door to the hallway closed when performing [MEDICAL CONDITION] care. The DON answered Yes. 2. The facility's Assistance with Meals policy documented, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Nursing staff and/or Feeding Assistants will feed those residents needing full assistance within (blank) minutes of this delivery of food trays . Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] documented, Resident #145 had severe cognitive impairment. Observations in the restorative dining room on 12/3/17 at 11:40 AM, revealed Resident #145 was served her lunch tray but was not assisted with her lunch until 12:28 PM, 52 minutes after the tray was placed in front of her. Interview with the DON on 12/7/17 at 5:23 PM in the conference room, the DON confirmed it was not acceptable for a resident to wait 52 minutes before being assisted with their meal.",2020-09-01
1077,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2017-12-05,684,D,1,1,7XFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to schedule a follow up physician's appointment for 1 of 3 (Resident #325) sampled residents. The findings included: 1. The facility's PHYSICIAN STANDING ORDERS policy documented, .Physician orders [REDACTED]. 2. Medical record review revealed Resident #325 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Discharge Activity Follow Up Instructions from (Named Hospital) dated 8/4/17 documented, .call for follow up appointment in 12 days . Interview with the Social Service Director, (SSD) on 12/6/17 at 9:15 AM in the conference room, the SSD was asked whose responsibility it was to make follow up physician appointments. The SSD stated, .I made the ortho (orthopedic) appointment as soon as the daughter brought it to my attention .normally the nurses will let me know when a resident is to have a follow up appointment . Interview with the Director of Nursing (DON) on 12/6/17 at 9:20 AM in the conference room, the DON was asked what the procedure was for making follow up physician appointments. The DON stated, .the nurses let social service know when a new resident gets an order for [REDACTED].",2020-09-01
1078,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2017-12-05,689,D,0,1,7XFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 6 (Resident #23) sampled residents were free from accident hazards by failing to refer Resident #23 to therapy after the resident experienced a fall. The findings included: 1. The facility's PR[NAME]EDURE: POST FALL policy documented, . Nursing to complete per policy and procedure .Fall Tracking form .Resident will be referred to therapy for screen - screening will indicate need of therapy interventions . 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] and the admission MDS revealed Resident #23 was cognitively impaired. Review of the Resident Incident Report dated 9/25/17, 9/30/17, 10/10/17 and 11/17/17 revealed Resident #23 was not referred to therapy for screening after experiencing falls per policy and procedure. Interview with the Therapy Program Manager (TPM) on 12/7/17 at 10:00 AM in the TPM's office, the TPM was asked if PT had a referral for a therapy screen on 9/25/17, 9/30/17, 10/10/17, and 11/17/17 after Resident #23 experienced falls. The TPM stated, No. Interview with the Director of Nursing (DON) on 12/7/17 at 10:30 AM at the 500/800 nurses station the DON was asked if there should have been a referral for a therapy screen on the dates of 9/25/17, 9/30/17, 10/10/17, and 11/17/17 when Resident #23 experienced falls. The DON stated, .Yes .",2020-09-01
1079,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2017-12-05,770,D,0,1,7XFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to provide timely laboratory services to meet the needs of 1 of 1 (Resident #477) sampled residents. The findings included: The facility's Nursing Facility Guidelines policy documented .Incidental Laboratory Orders .Phone call notification is required for a .non-routine service day. Medical record review revealed Resident #477 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a PHYSICIAN TELEPHONE ORDER dated 11/28/17 for Resident #477 revealed an order for [REDACTED]. Review of the PHLEBOTOMY PATIENT SERVICE LOG revealed that the collection time for the sputum specimen was 10:55 AM on 12/1/17. Review of a LAB REPORT dated 12/1/17 at 1:59 PM documented, .Comment: The following tests were not performed SPUTUM CULTURE Specimen unacceptable due to delay of at least 48 hours between collecting specimen and requiring processing. Review of a PHYSICIAN TELEPHONE ORDER dated 12/4/17 revealed an order to recollect the sputum C & S as requested by the laboratory. Interview with the Director of Nursing (DON) on 12/7/17 at 2:45 PM in the conference room, the DON was asked if the facility failed to submit the collected sputum C & S to the laboratory timely resulting in a delay in receiving the results. The DON stated, Yes.",2020-09-01
1080,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2019-10-03,656,D,1,1,VBXZ11,"**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 the comprehensive care plan intervention of 2 person transfers via mechanical lift were implemented for 1 of 38 (Resident #6) sampled residents reviewed. The findings included: The facility's Care Plans-Comprehensive policy revised on 1/28/11 documented, .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels . Medical record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or more staff assist. The quarterly Minimum (MDS) data set [DATE] documented Resident #6 was assessed requiring extensive assistance of 2 persons with transfers. An Incident Report dated 9/6/19 documented, Resident was being transferred from w/c (wheelchair) c (with) Hoyer lift (type of mechanical lift) X 1 CNA (by 1 Certified Nursing Assistant), lift tilted over .resident fell on floor .0 (no) visible injuries . Observations in the Dining Room on 9/23/19 at 11:15 AM, revealed Resident #6 was up in a wheelchair eating the noon meal. There were no visible injuries noted. Observations in the Dining Room on 9/25/19 at 11:30 AM, revealed Resident #6 was seated in her wheelchair, participating in the activity. Observations in Resident #6's room on 10/1/19 at 4:05 PM, revealed Resident #6 lying in bed, appeared clean and well groomed. Interview with Licensed Practical Nurse (LPN) #1 on 9/23/19 at 1:00 PM, in the Conference Room LPN #1 was asked about Resident #6's fall. Licensed Practical Nurse (LPN) #1 stated, .The CNA was transferring (Resident #6) by herself and not supposed to, we transfer with 2 people for lifts . Interview with the Director of Nursing (DON) on 9/23/19 at 3:30 PM, in the Conference Room, the DON was asked about Resident #6's fall, the DON stated, .The CNA was new here, had been trained and her competency checked. We terminated her . Telephone interview with CNA #1 on 9/24/19 at 4:33 PM, CNA #1 was asked about Resident #6's fall, CNA #1 stated, (Named Resident #6) had been up and was ready to go to bed, really past ready Yes, I am aware to use 2 people with lifts . The facility failed to ensure that a mechanical lift transfer was conducted by 2 persons per the resident care plan.",2020-09-01
1081,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2019-10-03,689,D,1,1,VBXZ11,"**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 an environment was free of accident hazards for 2 of 5 (Resident #6 and #149) sampled residents reviewed for falls. The findings included: 1. The facility's Mechanical Lift policy revised 8/2016 revealed, The purpose of this procedure is to help lift residents using a manual lifting device .Two (2) nursing assistants will be required to perform any mechanical lift procedure . 2. Medical record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or more staff assist. The quarterly Minimum (MDS) data set [DATE] documented Resident #6 was assessed with [REDACTED]. An Incident Report dated 9/6/19 documented, Resident was being transferred from w/c (wheelchair) c (with) Hoyer lift (type of mechanical lift) X 1 CNA (by 1 Certified Nursing Assistant), lift tilted over . resident fell on floor .0 (no) visible injuries . Review of the emergency room record dated 9/6/19 revealed, .Fall .No fracture .discharged to home .no further workup or admission to hospital is needed . Observations in the Dining Room on 9/23/19 at 11:15 AM, revealed Resident #6 was up in a wheelchair eating the noon meal. There were no visible injuries noted. Observations in the Dining Room on 9/25/19 at 11:30 AM, revealed Resident #6 was seated in her wheelchair, participating in the activity. Observations in Resident #6's room on 10/1/19 at 4:05 PM, revealed Resident #6 lying in bed, appeared clean and well groomed. Interview with Licensed Practical Nurse (LPN) #1 on 9/23/19 at 1:00 PM, in the Conference Room LPN #1 was asked about Resident #6's fall. Licensed Practical Nurse (LPN) #1 stated, .The CNA was transferring (Resident #6) by herself and not supposed to, we transfer with 2 people for lifts . Interview with the Director of Nursing (DON) on 9/23/19 at 3:30 PM, in the Conference Room, the DON was asked about Resident #6's fall, the DON stated, .The CNA was new here, had been trained and her competency checked. We terminated her . Telephone interview with CNA #1 on 9/24/19 at 4:33 PM, CNA #1 was asked about Resident #6's fall, CNA #1 stated, (Named Resident #6) had been up and was ready to go to bed, really past ready .Yes, I am aware to use 2 people with lifts . The facility failed to ensure 2 person mechanical lift transfer was conducted for Resident #6. 3. Medical record review revealed Resident #149 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #149 with a BIMS of 15 out of 15 indicating no cognitive deficit and was nonambulatory. The care plan updated on 8/28/19 documented Resident #149 .requires air redistribution mattress . An Incident Report dated 9/20/19 documented, .unobserved fall .air mattress overlay slid off of mattress, mattress overlay not secured properly . An emergency room record dated 9/20/19 documented, .fell out of bed .abrasion above right eye .denies pain .symptoms is pain and swelling .degree at present is minimal . Observations in Resident #149's room on 9/23/19 at 11:20 AM, revealed Resident #149 lying in a bariatric bed with bolsters and half upper side rails up. When asked about his fall, Resident #149 reported he had been on a regular mattress with an air overlay that had vibrated slowly over and just slid off and he slipped off the side of the bed. Observations in Resident #149's room on 9/30/19 at 9:10 AM, revealed Resident #149 lying in a bariatric bed on an air mattress, watching television. Interview with the DON on 9/23/19 at 4:00 PM, in the Conference Room, the DON was asked how the air mattress slid off the bed. The DON stated, Housekeeping had changed out his mattress and did not properly reattach it. It slid partially off the bed causing (Named Resident #149) to slide off . Interview with LPN #2 on 9/30/19 at 12:30 PM, in the DON office LPN #2 was asked about what caused Resident #149 to fall off the bed, LPN #2 stated, .the sheet part was supposed to be fastened together under the bed .it wasn't. It slid partially off and he fell , no real injury . The facility failed to ensure Resident #149 's air mattress was attached properly and he was free of an accident hazard.",2020-09-01
1082,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2019-10-03,761,D,0,1,VBXZ11,"**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 stored and secured in 1 of 13 (500 Hall Medication Cart) medication storage areas. The findings include: 1. The facility's Medication Storage policy dated 9/18 documented, .Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorizes access . 2. Observations in the 500 Hall outside of the Secured Unit Dining Room on 9/30/19 at 4:24 PM, revealed an unlocked and unattended medication cart. Observations in the 500 Hall outside of room [ROOM NUMBER] on 9/30/19 at 4:30 PM, revealed an unlocked and unattended medication cart. Interview with the Director of Nursing (DON) on 10/2/19 at 4:23 PM, in the DON Office, the DON was asked if a medication cart should be left unlocked and unattended. The DON stated, No.",2020-09-01
1084,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2018-11-01,623,D,0,1,WIDU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide notice to the Ombudsman of transfers for 2 of 5 (Resident #83 and 167) sampled residents reviewed for discharge requirements. The findings included: 1. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses' Notes dated 7/13/18 revealed Resident #83 was transferred to the emergency room . Review of the Nurses' Notes dated 7/26/18 revealed Resident #83 was transferred to the emergency room . The facility was unable to provide documentation the Ombudsman was notified of the transfer to the hospital on [DATE] and 7/26/18. 2. Medical record review revealed Resident #167 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].send pt (patient) to (Named Hospital) r/t (related to) mental status change, abnormal vitals, and abnormal labs . The facility was unable to provide documentation the Ombudsman was notified of the transfer to the hospital on [DATE]. Interview with the Social Worker on 10/31/18 at 4:19 PM, in the conference room, the Social Worker was asked if the Ombudsman was notified when a resident was transferred to the hospital. The Social Worker confirmed the Ombudsman was not notified and stated, I was just assigned this in (MONTH) .I'm working on (MONTH) .I don't believe it was done .I will be doing it this point forward .",2020-09-01
1085,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2018-11-01,686,D,0,1,WIDU11,"**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 care and services for the treatment of [REDACTED].#96 and 123) sampled residents reviewed with pressure injuries. The findings included: 1. The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy dated 11/28/17 documented, .Purpose .Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .Treatment/Management .1. The physician will authorize pertinent orders related to wound treatments . 2. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #96 had a Stage 1 or greater pressure ulcer, unhealed pressure ulcers, and 2 stage 3 pressure ulcers. The physician's orders [REDACTED].Cleanse with wound cleanser or normal saline. Pat dry, skin prep periwound. Apply Collagen Alginate as directed to Sacrum. Cover with a silicone dressing. every day shift every other day AND as needed for wound care . Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARS) revealed no documentation these treatments were performed as ordered or refused on 4/24/18, 5/2/18, 5/4/18, 5/28/18, and 5/30/18. The physician's orders [REDACTED].Cleanse with wound cleanser or normal saline. Pat dry. Skin prep barrier wipe to peri wound Apply Med Honey Alginate as directed to Sacral/Coccyx. Cover with Silicond (Silicone) dressing every other day and prn (as needed) every day shift every other day for wound care AND as needed for wound care . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 6/21/18. The physician's orders [REDACTED].Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to Sacral/Coccyx topically as needed for wound care AND Apply to Sacral/Coccyx topically every day shift related to PRESSURE ULCER OF SACRAL REGION, STAGE 3 .Cleanse with wound cleanser or normal saline, pat dry. Apply Santyl to wound base as directed. Skin barrier wipe to peri wound, and cover with a dry dressing . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 7/22/18 and 7/23/18. The physician's orders [REDACTED].Cleanse with wound cleanser or normal saline. Pat dry. Apply Collagen as directed to Sacral/coccyx. Skin barrier wipe to peri wound. Cover with Silicone dressing every day shift every 2 day(s) for Pressure wound AND as needed . Review of the July, August,, and (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 7/22/18, 7/23/18, 8/3/18, 8/6/18, 8/20/18, 8/22/18, and 10/5/18. The physician's orders [REDACTED].Santyl Ointment 250 UNIT/GM (Grams) ([MEDICATION NAME]) Apply to Right Upper Buttock topically every day shift for wound care Cleanse with wound cleanser. Pat dry. Apply Santyl to wound base Right Upper Buttock then cover calcium Alginate. Skin barrier wipe to peri wound. Cover with Silicone every day and prn AND Apply to Right Upper Buttock topically as needed for wound care . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 6/16/18 and 6/20/18. The physician's orders [REDACTED].Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to Right Upper Buttock topically every day shift for wound care Cleanse with wound cleanser. Pat dry. Apply Santyl to wound base Right Upper Buttock then cover calcium Alginate. Skin barrier wipe to peri wound. Cover with Silicone every day and prn AND Apply to Right Upper Buttock topically as needed for wound care . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 7/22/18 and 7/23/18. The physician's orders [REDACTED].Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to left mid buttock topically every day shift related to PRESSURE ULCER OF RIGHT BUTT[NAME]K .AND Apply to right buttock topically as needed for wound care related to PRESSURE ULCER OF RIGHT BUTT[NAME]K . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 6/25/18. The physician's orders [REDACTED].NPWT (Negative Pressure Wound Therapy) for wound: Cleanse wound with wound cleanser or normal saline, pat dry. Apply skin prep to peri wound, fill dead space with black foam. Cover with sealant cover film and apply NPWT tubing. every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for Right upper buttock/ pressure wound AND as needed . Review of the (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 8/3/18 and 8/6/18. The physician's orders [REDACTED].Cleanse wound with wound cleanser or normal saline, pat dry. Apply skin prep to peri wound, Apply collagen and Calcium Alginate to Upper Right buttock cover with silicone dressing every day shift every Mon, Wed, Fri for Right upper buttock/pressure wound AND as needed . Review of the August, September, and (MONTH) (YEAR) TARS revealed no documentation these treatments were performed as ordered or refused on 8/20/18, 8/22/18, and 10/5/18. Wound care observations in Resident #96's room on 10/31/18 at 11:05 AM, revealed Resident #96 was in the bed, appeared clean, a special air mattress to her bed was noted, she had a Stage 3 pressure injury to the sacrum and the right buttock. Interview with Licensed Practical Nurse (LPN) #1 (the Treatment Nurse) on 10/31/18 at 12:06 PM, in the conference room, she confirmed the TARS should not have missing documentation and stated, No should not have blanks . LPN #1 was shown these TARS with the missing documentation and asked if the TARS should either document the treatments were done or the treatments were refused. LPN #1 stated, Yes. 3. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and quarterly MDS dated [DATE] revealed Resident #123 had a Stage 1 or greater pressure ulcer, an unhealed pressure ulcer, and 1 stage 4 pressure ulcer which was present on admission. The physician's orders [REDACTED].Cleanse with wound cleanser or normal saline. Pat dry, apply polymem as directed to sacrum. Cover with a silicone dressing. as needed for wound care AND every day shift every other day . Review of the (MONTH) and (MONTH) (YEAR) TARS revealed these treatments were not performed as ordered or refused on 4/2/18, 4/4/18, 4/10/18, 4/12/18, 4/20/18, 4/24/18, 4/26/18, 5/2/18, 5/4/18, 5/28/18, and 5/30/18. Review of the Order Summary Report dated 7/27/18 revealed, .Cleanse with wound cleanser or Normal Saline. Pat dry. Apply Calcium Alginate Ag as directed to Sacral/coccyx. Skin barrier wipe to peri wound. Cover with Silicone dressing every day shift . Review of the (MONTH) (YEAR) TAR revealed that these treatments were not performed as ordered or refused on 8/3/18, 8/6/18, 8/16/18, 8/20/18-8/22/18, and 8/25/18. Wound care observations in Resident #123's room on 10/31/18 at 9:33 AM, revealed Resident #123 was in the bed, appeared clean, a special air mattress to his bed was noted, and he had a Stage 4 pressure wound to the sacrum. Interview with LPN #1 on 10/31/18 at 5:29 PM, in the conference room, LPN #1 was shown the TARS with blank dates and asked if there should be blanks on the TARS. LPN #1 confirmed the TARS should not have blanks but should document either the treatment was provided as ordered or resident refusal of treatment. Interview with the Director of Nursing (DON) on 11/1/18 at 9:11 AM, in the DON office, the DON was shown the TAR and asked what the blanks on the TAR meant. The DON stated, (Named LPN #1) omitted some documentation .if it is not documented it is not done . The DON confirmed it was not acceptable for treatments not to be done.",2020-09-01
1086,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2018-11-01,880,D,0,1,WIDU11,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 5 (Licensed Practical Nurse (LPN) #2 and 3) nurses administering medications failed to perform hand hygiene and failed to change the enteral tubing when it was contaminated, when Certified Nursing Assistant (CNA) #1 picked up a pillow from the floor and placed it under Resident #47's legs, and when 1 of 5 (Resident #137) sampled resident's catheter bag and tubing were observed on the floor. The findings included: 1. The facility's Bulb/plunger Syringes, Sanitizing . revised 2/2018 documented, .Wash hands thoroughly with soap and water .After changing/removing gloves . Observations in Resident #5's room on 10/29/18 beginning at 12:20 PM, revealed LPN #2 disconnected the tube feeding tubing from Resident #5's enteral feeding tube. LPN #2 dropped the tube feeding tubing, and the insertion tip of the tubing touched Resident #5's gown. Interview with LPN #2 on 10/31/18 at 2:48 PM, at the entrance to the Secure Unit dining room, LPN #2 was asked if it was appropriate for the tip of the tube feeding tubing to touch the patient's gown. LPN #2 stated, No, it shouldn't touch anything. When that happens it should be totally changed out. Observations in Resident #70's room on 10/31/18 beginning at 11:15 AM, revealed LPN #3 allowed the needle tip on an insulin syringe to touch Resident #70's gown. LPN #3 used the contaminated insulin syringe to administer a subcutaneous injection to Resident #70. Observations in Resident #130's room on 10/31/18 beginning at 1:55 PM, revealed LPN #3 removed the plunger from a syringe during medication administration. LPN #3 removed her gloves and donned clean gloves without performing hand hygiene. Interview with LPN #3 on 10/31/18 at 2:01 PM, at the 100 hall medication cart, LPN #3 was asked if a needle tip should touch a resident's gown. LPN #3 stated, No, ma'am, not at all. LPN #3 was asked what nurses should do between removing dirty gloves and donning clean gloves. LPN #3 stated, Wash your hands. Interview with the Assistant Director of Nursing (ADON) on 11/1/18 at 1:44 PM, outside the ADON office, the ADON was asked if it was appropriate for a syringe needle tip to touch a resident's gown. The ADON stated, No. The ADON was asked if it was appropriate for the tip of tube feeding tubing to touch a resident's gown. The ADON stated, No, it should be placed in the cap. The ADON confirmed that needles and feeding tube tubing should not be contaminated before using them to administer medications or tube feeding to residents. 2. Review of the facility's Making an Occupied Bed policy dated 1/2011 documented, .to provide the resident with a clean and comfortable environment and to prevent skin irritation and breakdown .Remove the soiled case and put the clean case on the pillow .Do not let the soiled linen touch the floor. Discard it in the soiled laundry container . Observations in Resident #47's room on 10/31/18 at 9:03 AM, while providing perineal care, CNA #1 dropped Resident #47's pillow on the floor, picked the pillow up and placed it back on the bed, under Resident #47's legs, without replacing the pillow case. Interview with LPN #4 on 10/31/18 at 9:21 AM, in the 100 Hall, LPN #4 was asked if it was acceptable for a staff member to pick a pillow up from the floor and place it back on the bed. LPN #4 stated, No ma'am, she should have changed the pillowcase. Interview with the DON on 11/1/18 at 9:11 AM, in the DON office, the DON was asked if it was acceptable to pick up a pillow off the floor and place it back on a resident's bed. The DON stated, No, it's not. 3. The facility's Catheter Care, Urinary policy revised 3/23/11 documented, .Be sure the catheter tubing and drainage bag are kept off the floor . Observations in Resident #137's room on 10/30/18 at 7:51 AM and 9:52 AM, revealed Resident #137's urinary catheter bag lying on the floor. Observations in Resident #137's room on 11/1/18 at 7:46 AM, revealed Resident #137's catheter bag and tubing lying on the floor. Interview with the Infection Control Nurse on 10/31/18 at 3:16 PM, in the conference room, the Infection Control Nurse was asked if urinary catheter bags and tubing should be lying on the floor. The Infection Control Nurse stated, No, ma'am.",2020-09-01
1087,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2017-11-15,282,D,0,1,3U5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure staff followed the care plan for the management of pressure ulcers and respiratory problems for 2 of 14 (Resident #158 and 245) sampled residents reviewed of the 29 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/4/16 reviewed 10/26/17, documented, .Pressure ulcer .Alteration in skin integrity R/T (related to) pressure wound to (sacrum) .Interventions .pressure relieving devices for bed/chair . Observations in Resident #158's room on 11/14/17 at 9:28 AM, 2:11 PM, and 5:02 PM, revealed Resident #158 in the bed. The power was off on the pressure mattress pump, and it was not functioning. Interview with Licensed Practical Nurse (LPN) #2 on 11/14/17 at 9:31 AM, on the 300 hall, LPN #2 confirmed Resident #158 had a stage 4 pressure ulcer to the sacral area. Interview with Registered Nurse (RN) #2 on 11/14/17 at 5:02 PM, in Resident #158's room, RN #2 confirmed the pressure mattress pump was not functioning. Observations in Resident #158's room on 11/14/17 at 5:05 PM, revealed Maintenance Staff Member #1 entered room, assessed the pressure mattress pump, reattached the cord to the pressure mattress pump, and turned the mattress on. Maintenance Staff Member #1 stated, .it had wrapped around (the side rail) and came unplugged (from the pressure mattress pump) . Interview with the Director of Nursing (DON) on 11/15/17 at 3:32 PM, in the Family Room, the DON was asked whether it was acceptable that Resident #158's pressure mattress pump was off during observations on 11/14/17 from 9:28 AM to 5:02 PM. The DON stated, No . 2. Medical record review revealed Resident #245 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/24/17 documented, .Risk for impaired gas exchange R/T (related to) hx (history of) altered oxygenation .OSA (Obstructive Sleep Apnea) .Interventions .[MEDICAL CONDITION] (Continuous Positive Airway Pressure) as tolerated . The physician's orders [REDACTED].[MEDICAL CONDITION] as tolerated per pt (patient) at HS (bedtime) and removed in am (morning) .Order Date .10/24/2017 . Observations in Resident #245's room on 11/13/17 at 3:08 PM, 11/14/17 at 2:42 PM, and on 11/14/17 at 7:38 PM, revealed a [MEDICAL CONDITION] mask on the bedside table. No [MEDICAL CONDITION] machine was observed. Interview with Resident #245 on 11/13/17 at 3:08 PM, in his room, Resident #245 stated he was supposed to be using the [MEDICAL CONDITION], but the facility did not have the appropriate adaptor. Resident #245 was asked whether he had asked the nursing staff about the [MEDICAL CONDITION]. Resident #245 stated they were aware. Interview with RN #1 on 11/13/17 at 4:07 PM, on the 100 hall, RN #1 was asked whether Resident #245 used a [MEDICAL CONDITION] since he had been at the facility. RN #1 stated it was his understanding that Respiratory Therapy (RT) had said that Resident #245's family would have to bring his own [MEDICAL CONDITION] from home to the facility. RN #1 stated he would check into it. Interview with Resident #245 on 11/14/17 at 2:42 PM, in his room, Resident #245 was asked whether he had been provided a [MEDICAL CONDITION] machine. Resident #245 stated, No, they didn't bring it. Interview with LPN #1 on 11/14/17 at 7:50 PM, in Resident #245's room, LPN #1 was asked about the [MEDICAL CONDITION] machine. LPN #1 confirmed there was no [MEDICAL CONDITION] machine. LPN #1 stated, Let me check and see how we can get you a temporary machine . Interview with the Director of Nursing (DON) on 11/14/17 at 8:00 PM, in her office, the DON was asked whether it was acceptable for Resident #245 not to have a [MEDICAL CONDITION] machine, since he had physician orders [REDACTED]. The DON stated, I usually have Respiratory (RT) do that. The DON was asked what she does if residents have orders for a [MEDICAL CONDITION], but do not have a machine to use at the facility. The DON stated, We get the settings from the physician, and get RT to get them set up. Interview with Resident #245 on 11/15/17 at 8:28 AM, in his room, Resident #245 was asked whether he had been provided a [MEDICAL CONDITION] machine yet. Resident #245 stated he was told he would have to bring his [MEDICAL CONDITION] machine from home. Interview with RT #1 on 11/15/17 at 9:38 AM, at the 400 hall nurses' station, RT #1 was asked whether she was aware Resident #245 did not have a [MEDICAL CONDITION] machine according to his physician's orders [REDACTED].#1 confirmed she was aware. RT #1 stated, .I never got orders for [MEDICAL CONDITION] settings .",2020-09-01
1088,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2017-11-15,314,D,0,1,3U5811,"**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 wound care in a manner that promoted healing and prevented the potential spread of infection for 1 of 2 (Resident #158) sampled residents reviewed with pressure ulcers. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .Employees will wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .After removing gloves .If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% (percent) [MEDICATION NAME] or [MEDICATION NAME] for all the following situations .Before handling clean or soiled dressings, gauze pads .Before moving from a contaminated body site to a clean body site during resident care .After handling used dressings, contaminated equipment .After removing gloves .The use of gloves does not replace handwashing/hand hygiene . 2. Medical record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented Resident #158 was comatose in a persistent vegetative state, was totally dependent on staff for all activities of daily living (ADLs), was at risk for pressure ulcers, and had 1 stage 4 pressure ulcer that was present on admission. The skin and ulcer treatment included pressure reducing devices for bed and chair, nutrition/hydration program, pressure ulcer care, and application of nonsurgical dressings and ointments/medications other than to feet. The care plan dated 4/4/16, and last reviewed 10/26/17, documented, .Pressure ulcer. Alteration in skin integrity R/T (related to) pressure wound to (sacrum) .Interventions .pressure relieving devices for bed/chair . Observations in Resident #158's room on 11/14/17 at 9:28 AM, 2:11 PM, and 5:02 PM, revealed Resident #158 lying in bed. The power was off on the pressure mattress pump, and it was not functioning. Interview with Licensed Practical Nurse (LPN) #2 on 11/14/17 at 9:31 AM, on the 300 hall, LPN #2 confirmed Resident #158 had a stage 4 pressure ulcer to the sacral area. Interview with Registered Nurse (RN) #2 on 11/14/17 at 5:02 PM, in Resident #158's room, RN #2 confirmed the pressure mattress pump was not functioning. Observations in Resident #158's room on 11/14/17 at 5:05 PM, revealed Maintenance Staff Member #1 entered the room, assessed the pressure mattress pump, reattached the cord to the pressure mattress pump, and turned the mattress on. Maintenance Staff Member #1 stated, .it had wrapped around (the side rail) and came unplugged (from the pressure mattress pump) . Wound care observations in Resident #158's room on 11/15/17 beginning at 10:12 AM, revealed LPN #2 performed wound care on the stage 4 pressure ulcer to Resident #158's sacral area. Observations of the resident's sacral area revealed a half-dollar sized open wound with granulation tissue to the wound bed, and also 2 smaller 1/2 to 1 centimeter pink open areas. LPN #2 stated the smaller areas were from a skin condition (Pemphigoid) and stated she would begin new treatment with Dermaseptin that was ordered for Resident #158 on an as needed basis. LPN #2 cleaned the sacral area wounds with wound cleanser, changed gloves without performing hand hygiene twice during cleansing, dried the sacral area with gauze, changed gloves without performing hand hygiene, packed the open wound with Silver [MEDICATION NAME]-soaked gauze, and applied Dermaseptin to the buttocks using a gloved hand without performing hand hygiene. LPN #2 then changed gloves again, and applied the Allevyn dressing. LPN #2 failed to perform hand hygiene after removing soiled gloves during wound care. Interview with the Director of Nursing (DON) on 11/15/17 at 3:32 PM, in the Family Room, the DON was asked what she expected nursing staff to do during wound care after cleansing the wound and removing gloves. The DON stated, Wash their hands. The DON was asked whether it was acceptable that Resident #158's pressure mattress pump was off during observations on 11/14/17 from 9:28 AM to 5:02 PM. The DON stated, No .",2020-09-01
1089,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2017-11-15,328,D,0,1,3U5811,"**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 physician's orders were followed for a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) device, and failed to follow the facility's policy for Oxygen administration for 1 of 2 (Resident #245) sampled residents reviewed for respiratory services. The findings included: 1. The facility's Oxygen Administration policy documented, .The purpose of this procedure is to provide guidelines for safe oxygen administration .The following equipment and supplies may be necessary .Humidifier bottle .while the resident is receiving oxygen therapy .assess the resident for the following .Check the .humidifying bottle .to be sure they are in good working order .Be sure there is water in the humidifying bottle and that the water level is high enough that the water bubbles as oxygen flows through .Periodically re-check water level in humidifying bottle . 2. Medical record review revealed Resident #245 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 14, indicating no cognitive impairment, had shortness of breath with exertion, and received Oxygen therapy while a resident at the facility. The MDS was not coded for use of a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) device while a resident at the facility. The care plan dated 10/24/17 documented, .Risk for impaired gas exchange R/T (related to) hx (history of) altered oxygenation .OSA (Obstructive Sleep Apnea) .Interventions .C PAP as tolerated . The physician's orders documented, .Start Date .10/24/2017 .O2 (Oxygen) @ (at) 2 L/M (Liters per Minute) BNC (By Nasal Cannula) PRN (As Needed) for SOB (Shortness of Breath) .Start Date .10/24/2017 .[MEDICAL CONDITION] as tolerated per pt (patient) at HS (bedtime) and removed in am (morning) every evening shift for OSA AND every night shift for OSA .Order Date .10/24/2017 . Observations in Resident #245's room on 11/13/17 at 3:08 PM, revealed a [MEDICAL CONDITION] mask on the bedside table. No [MEDICAL CONDITION] machine was observed. Observations in Resident #245's room on 11/14/17 at 2:42 PM, revealed Resident #245 sitting on the bedside with O2 on at 2 L/M BNC per O2 concentrator at bedside. The O2 humidifier bottle was empty. The [MEDICAL CONDITION] mask was on the bedside table. There was no [MEDICAL CONDITION] machine. Observations in Resident #245's room on 11/14/17 at 7:38 PM, revealed Resident #245 lying in bed with O2 on at 2 L/M BNC. The O2 humidifier bottle was empty. There was no [MEDICAL CONDITION] machine. Interview with Resident #245 on 11/13/17 at 3:08 PM, in his room, Resident #245 stated he was supposed to be using the [MEDICAL CONDITION], but the facility did not have the appropriate adaptor. Resident #245 was asked whether he had asked the nursing staff about the [MEDICAL CONDITION]. Resident #245 stated they were aware. Interview with Registered Nurse (RN) #1 on 11/13/17 at 4:07 PM, on the 100 hall, RN #1 was asked whether Resident #245 used a [MEDICAL CONDITION] since he had been at the facility. RN #1 stated it was his understanding that Respiratory Therapy (RT) had said that Resident #245's family would have to bring his own [MEDICAL CONDITION] from home to the facility. RN #1 stated he would check into it. Interview with Resident #245 on 11/14/17 at 2:42 PM, in his room, Resident #245 was asked whether he had been provided a [MEDICAL CONDITION] machine. Resident #245 stated, No, they didn't bring it. Interview with Licensed Practical Nurse (LPN) #1 on 11/14/17 at 7:45 PM, at the 100 hall nurses' station, LPN #1 was asked whose responsibility it was to keep the O2 concentrator humidifiers maintained/filled. LPN #1 stated, 11-7 nurses. They do that every Thursday night and PRN. LPN #1 was asked whether the O2 humidifier bottles should be allowed to run dry. LPN #1 stated, No. Interview with LPN #1 on 11/14/17 at 7:50 PM, in Resident #245's room, LPN #1 confirmed the O2 humidifier bottle was empty. LPN #1 was asked whether it was acceptable for the O2 humidifier bottle to be empty during oxygen administration. LPN #1 stated, No. LPN #1 confirmed there was no [MEDICAL CONDITION] machine. LPN #1 stated, Let me check and see how we can get you a temporary machine . Interview with the Director of Nursing (DON) on 11/14/17 at 8:00 PM, in her office, the DON was asked whether it was acceptable for Resident #245 not to have a [MEDICAL CONDITION] machine, since he had physician orders and was care-planned for it. The DON stated, I usually have Respiratory (Therapy)(RT) do that. The DON was asked what she does if residents have orders for a [MEDICAL CONDITION], but do not have a machine to use at the facility. The DON stated, We get the settings from the physician, and get RT to get them set up. Interview with Resident #245 on 11/15/17 at 8:28 AM, in his room, Resident #245 was asked whether he had been provided a [MEDICAL CONDITION] machine yet. Resident #245 stated he was told he would have to bring his [MEDICAL CONDITION] machine from home. Interview with RT #1 on 11/15/17 at 9:38 AM, at the 400 hall nurses' station, RT #1 was asked whether she was aware Resident #245 did not have a [MEDICAL CONDITION] machine according to his physician's orders/care plan. RT #1 stated, They called me one day, and I went over there. His sister or somebody was supposed to bring his [MEDICAL CONDITION] up . RT #1 was asked how she was notified if someone needed a [MEDICAL CONDITION]. RT #1 stated, .Once a patient with a [MEDICAL CONDITION] comes in the building, the nurse or the DON notifies me. They have to get the settings from a doctor's order. If the doctor doesn't send the proper orders, I cannot do that .I never got orders for [MEDICAL CONDITION] settings.",2020-09-01
1090,THE KINGS DAUGHTERS AND SONS,445221,3568 APPLING ROAD,BARTLETT,TN,38133,2018-02-14,577,D,0,1,1QTY11,"Based on policy review, observation, and interview, the facility failed to ensure the recent survey results were readily accessible for all residents residing in the facility. The facility has a census of 104 residents. The findings included: 1. The facilities policy's Resident Rights documented the following .The resident has a right to .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors . Observation in the reception area on 2/13/18 at 3:45 PM, revealed a white binder with 9/4/14, 10/21/15, and 12/7/16 survey results. The reception area was behind a closed door, not readily available to residents and family. Interview with Resident Council attendees (Resident #14, 20, 28, 33, 36, who were identified as alert and oriented by the facility) on 2/13/18 at 3:04 PM, in the dining room, attendees stated they did not know where the results of the last survey were located. Interview with the Administrator on 2/13/18 at 3:41 PM, in the Admission office, the Administrator was asked if residents had free access to survey results. The Administrator stated, They can always ask to see them.",2020-09-01
1091,THE KINGS DAUGHTERS AND SONS,445221,3568 APPLING ROAD,BARTLETT,TN,38133,2019-07-17,609,D,1,0,GL8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, Facility Reported Incident (FRI) review, medical record review, and interview, the facility failed to report an allegation of abuse and neglect within 2 hours for 1 of 3 (Resident #1) sampled residents reviewed. The findings include: Review of the undated facility Abuse Prevention Policy documented, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment revealed Resident #1 scored a 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively intact for decision making. Review of the Event Report dated 7/8/19 documented, .Administrator was notified of allegation of abuse on 7/8/19 at approximately 12 PM by (named person) MDS Coordinator .Ms. (Resident #1's) daughter reported that on 6/24/19 a certified nursing assistant (CNA) had come into her mother's room to put her to bed and grabbed her by the arm and the back of the pants, attempting to transfer her without a lift. She stated that in doing this she dropped her on the floor. She stated the certified nursing assistant then roughly picked her mother up off the floor and put her back in the bed and never told anyone the incident occurred . Review of the FRI revealed the incident was reported to the State Agency on 7/9/19 at 5:44 PM. Interview on 7/17/19 at 10:30 AM in the conference room, the MDS Coordinator confirmed her witness statement. She stated, .( (Resident #1's daughter) came to me on 7/8/19 at approximately 12 noon and informed me that (Resident #1) had been abused on 6/24/19 by a CNA because she was yanked on the arm and put in the bed .I immediately informed the Administrator there was an allegation of abuse . Interview on 7/17/19 at 2:00 PM with the Assistant Director of Nursing (ADON) in the conference room, the ADON confirmed the abuse allegation was reported to the State Agency by the Administrator on 7/9/19, 24 hours after the facility received the allegation of abuse. The ADON stated, .The Administrator said she thought she had 24 hours .",2020-09-01
1093,SOUTHERN TENN MEDICAL CENTER SNF,445222,629 HOSPITAL ROAD,WINCHESTER,TN,37398,2019-05-08,758,D,0,1,INHS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to monitor behaviors and side effects for [MEDICAL CONDITION] medications for 1 resident (#116) of 5 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physicians Orders revealed the following: 4/30/19- [MEDICATION NAME] (medication to treat depression) 50 milligrams (mg) po (by mouth) QHS (every night time) 4/30/19- Mirtazepine (medication to treat depression) 15 mg po Q HS Medical record review of the facility Psychoactive Drug Monitoring dated 5/4/19 and 5/5/19, revealed .Does the patient receive Psychoactive Drugs .N (No) . Observation and interview of Resident #116 on 5/6/19 at 12:55 PM, in the residents room revealed the resident was alert and oriented, sitting up in a recliner chair. Interview with the Director of Nursing on 5/8/19 at 9:05 AM, in the conference room confirmed Resident #116 did receive 2 [MEDICAL CONDITION] medications and the facility failed to monitor for side effects and behaviors for the antidepressant medications.",2020-09-01
1094,SOUTHERN TENN MEDICAL CENTER SNF,445222,629 HOSPITAL ROAD,WINCHESTER,TN,37398,2018-05-16,640,D,0,1,K1DK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete and failed to submit the Minimum Data Sets (MDS) 14 days after completion for 4 residents (#1, #3, #10, #11) of 8 residents reviewed for MDS assessments. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE] after a 5 day length of stay at the facility. Medical record review revealed 1 MDS assessment for the resident, coded as a 5 day SNF PPS (skilled nursing facility prospective payment system) Part A Discharge (End of Stay) Assessment with a Due Date of 3/9/18. Continued review of the 5 day MDS revealed it was signed by the MDS Licensed Practical Nurse (LPN) #1 on 5/1/18. Further review revealed the MDS Registered Nurse (RN) #1 documented the 5 day assessment was complete and ready for submission on 5/1/18. Continued review revealed the 7 day timeframe to complete the assessment after discharge was not met and the 14 day submission requirement after completion of assessment was not met. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE] for a 21 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 3/31/18 was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Further review revealed the MDS was signed as complete by LPN #1 and RN #1 on 4/25/18. Continued review revealed the Due Date of 3/31/18 to complete the assessment after 14 days in the facility was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged on [DATE] after a 56 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 11/22/17 was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Further review revealed the MDS was signed as complete by RN #1 on 12/7/17, 31 days after admission and 17 days after a 14 day comprehensive assessment was due. Continued review revealed the Due Date of 11/22/17 to complete the assessment after 14 days in the facility was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed the 14 day scheduled assessment with a Due Date 11/29/17 was completed by RN #1 on 1/2/18. Continued review revealed the Due Date of 11/29/17 was not met and the 14 day submission requirement after completion of the assessment was not met. Medical record review revealed a 30 day scheduled assessment with a Due Date of 12/14/17 was not met. Continued review revealed the MDS areas LPN #1 was responsible for were completed on 5/16/18, and the 30 day MDS was not completed by RN #1. Medical record review revealed the SNF PPS Part A Discharge (End of Stay) Assessment, with a Due Date of 1/11/18 had not been completed by RN #1 as of 5/16/18. Continued review revealed the timeframe to complete the MDS within 7 days after the discharge (on 1/2/18) was not met, and the discharge MDS had not been submitted by the facility. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged on [DATE] after a 17 day length of stay at the facility. Medical record review revealed a 5 day scheduled assessment with a Due Date of 1/4/18 was the initial MDS assessment. Further review revealed the MDS was signed as complete by RN #1 on 5/15/18, 4 months after completion was required. Continued review revealed the 14 day scheduled assessment with a Due Date of 1/18/18 was signed complete by RN #1 on 5/15/18, more than 3 months after completion was required. Interview with LPN #1, on 5/15/18 at 4:30 PM, in room [ROOM NUMBER] confirmed she was responsible for coordinating and completing the MDS assessments. Continued interview confirmed .not able to get the MDS work done for several months .pulled to cover the units . Interview with the Administrator on 5/16/18 at 9:50 AM, in room [ROOM NUMBER], confirmed staffing and software issues had contributed to the MDS assessments not being completed in the required CMS (Centers for Medicare/Medicaid Services) timeframes.",2020-09-01
1095,SOUTHERN TENN MEDICAL CENTER SNF,445222,629 HOSPITAL ROAD,WINCHESTER,TN,37398,2018-05-16,656,D,0,1,K1DK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a comprehensive care plan for 3 residents (#3, #10, and #114) of 3 residents reviewed with lengths of stay at the facility greater than 20 days. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged from the facility on 4/7/18 after a 21 day stay. Medical record review revealed a 5 day scheduled assessment was the initial Minimum Data Set (MDS) assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Continued review revealed the resident did not have a comprehensive care plan included in the closed medical record. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident discharged from the facility on 1/2/18 after a 56 day stay. Medical record review revealed a 5 day scheduled assessment was the initial MDS assessment. Continued review revealed the Care Area Assessment was included in the 5 day MDS. Review continued and revealed the resident did not have a comprehensive care plan in the closed medical record. Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident in his room on 5/14/18 at 11:10 AM, revealed he was lying in bed watching TV and did not offer any complaints. Interview with LPN #1, responsible for coordinating the comprehensive care plans, on 5/16/18 at 9:30 AM, in room [ROOM NUMBER], confirmed a comprehensive care plan was due on 5/12/18 and the present care plan, dated 5/10/18, did not address the resident's Care Assessment Areas for providing assistance with ADL's (Activities of Daily Living), to address being at risk for Dehydration, and to address being at high risk for Falls. Interview with the Director of Nurses on 5/16/18 at 11:30 AM, in room [ROOM NUMBER], revealed .the comprehensive care plans .haven't been doing from the Care Area Assessments.",2020-09-01
1096,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2020-01-22,609,D,1,0,CLGJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interview, the failed to report an injury of undetermined origin with a fracture for 1 resident (#2) of 3 residents surveyed for incidents or accidents. The findings included: Review of a facility policy titled Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan, undated, showed .all injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated.injury is classified as injury of unknown origin when.the source of the injury was not observed by any person.or.could not be explained by the resident.The Administrator.or.Director of Nursing is responsible for initial reporting.investigation of alleged violations.reporting of results to proper authorities.the law requires facility staff to report investigate and document injuries. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 1/18/2020 showed on 1/18/2020 at approximately 6:20 AM Certified Nurse Aide (CNA #1) reported the onset of redness above the left eye of Resident #2 to the Registered Nurse (RN #1). RN #1 examined Resident #2, but took no further actions and did not report the injury to the oncoming nurse (RN #2) during the morning shift change at 7:00 AM. Review of a Nurse's Note and Change in Condition form dated 1/18/2020 at 12:00 PM showed the redness to Resident #2's left eye orbit had worsened, along with the development of swelling on her forehead and the onset of bruising to Resident #2's left hand. CNA #2 reported the change to RN #2. Review of a Nurse's Note dated 1/18/2020 at 10:34 PM showed Resident #2 had increased pain in her left leg and pelvis and x-rays of the leg were ordered at 3:00 AM. Review of a Radiology Imaging dated 1/19/2020 at 8:57 AM on 1/19/2020 showed the resident had a non-displaced [MEDICAL CONDITION] femoral neck (left [MEDICAL CONDITION]). Resident #2 was transported to a local hospital at 9:14 AM by Emergency Medical Services (nearly 27 hours after her initial injury was discovered). During a telephone interview with RN #2 on 1/22/2020 at 3:00 PM the RN stated he first became aware of the resident's injuries on 1/18/2020 around 12:00 PM. During a telephone interview with CNA #1 on 1/22/2020 at 4:22 PM the CNA reported she suspected Resident #2 had fallen and she had reported her suspicions to CNA #2 at shift change, but had not reported them RN #2. During a telephone interview with RN #1 on 1/22/2020 at 5:32 PM the RN stated CNA #2 informed her of Resident #2's injury. RN #1 stated she examined the resident, determined no signs of trauma were present, and did not consider the injury suspicious or reportable. RN #1 stated she did not recall if she reported Resident #2's injuries to RN #2. During an interview with the Administrator on 1/22/2020 at 6:28 PM, in the Administrator's office, the Administrator confirmed the facility failed to report injuries of undetermined origin involving a fracture timely. Continued interview confirmed the facility did not report the injury of unknown injury until 1/20/2020 (2 days after the injury).",2020-09-01
1097,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-09-25,689,D,1,0,V9FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, documentation review and interviews the facility failed to follow the facility's Fall Risk Management Policy for 1 resident (#1) of 3 residents reviewed for falls. The findings include: Review of a facility policy Fall Risk Management dated 2/12, revealed .A fall risk assessment needs to be completed on admission, after each fall .The fall risk care plan is to be updated after each fall . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of a 14 day Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, further review revealed the resident required extensive assistance with toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Review of a care plan dated 8/29/18 revealed .I am at moderate risk for falls r/t (related to) Confusion, Unaware of safety needs . Further review revealed no new fall precaution interventions for the fall occurring on 9/3/18. Review of an Incident Note dated 9/4/17 10:57 AM, revealed Late Entry: .assessed resident due to resident stating she had a fall .daughter in law present UA (Urine Analysis) with C &S (Culture and Sensitivity) ordered .C/O (complained of) her left knee being bruised observed left knee being swollen with some mild pale colored purple discoloration. Resident rubs this knee frequently possible arthritis per daughter in law. Left forearm observed to have various stages and colors of Ecchymosis. Actually on both arms. Next c/o headache states a pain goes to the crown of her head from her neck. Observed residents head .no discoloration or raised areas seen or felt. Daughter in law in agreement for series of x-rays on lateral skull, left forearm, left knee, order was placed stat . Review of a facility document Risk Management dated 9/3/18, revealed Resident #1 slid from her wheelchair head to toe assessment completed ROM (range of motion), pain assessed no injuries noted .Action .Falls Risk Evaluation .not created .IDT (interdisciplinary team): Therapy notified. Therapy to screen for positioning while up in wheelchair due to decreased safety awareness . Interview with the Registerd Nurse Supervisor on 9/24/18 at 6:15 PM, in the conference room confirmed Resident #1 had a documented fall on 9/3/18 at 6:12 AM. Continued interview confirmed the facility failed to follow their Fall Risk Management policy and did not complete a Falls Risk Assessment after a documented fall, and failed to update the fall risk care plan.",2020-09-01
1098,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-09-25,697,D,1,0,V9FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, observations and interviews, the facility failed to provide 3 scheduled doses of [MEDICATION NAME] HCL 20 mg tablet (medication to control pain) as ordered for 1 Resident (#2) of 3 residents reviewed. The findings include: Review of a facility policy, Medication Administration-General Guidelines, dated 11/08 revealed .Medications are administered in accordance with written orders of the attending physician .Medications are administered with 60 minutes of scheduled time . Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of a Care Plan dated 6/21/18, for Resident #2, revealed .I have chronic pain r/t (related to) Fracture multiple .Administer [MEDICATION NAME] as per orders . Review of a Physicians order dated 4/11/18, revealed .[MEDICATION NAME] HCL tablet 20 mg (milligram) Give 1 tablet every 4 hours for pain related to Radiculopathy [MEDICATION NAME] Region . Review of a Medication Administration Record [REDACTED].[MEDICATION NAME] HCL 20 Tablet 20 mg give one by mouth every 4 hours for pain . Continued review revealed on 9/23/18 Resident #2 was not administered his 12:00 AM dose, or his 4:00 AM dose. Continued review revealed the 8:00 AM, dose was signed off by Licensed Practical Nurse #1 as given. Further review revealed on 9/24/18, Resident #2 had rated his pain at a level of 2 at 12:00 AM, 4:00 AM, and at 8:00 AM. Observation/interview with Resident #2 on 9/24/18 at 10:20 AM, in his room, revealed the resident in his room lying in bed, awake and alert. Continued obsrvation revealed Resident #2 was not grimacing, moaning, or restless. Interview at this time revealed until last night he hadn't had any problems getting his medications. I haven't had my pain medication since 8:00 PM, last night, the nurse said they didn't have it. When asked if he had reported he was in pain he responded It wouldn't do any good they don't have it. Interview with Resident #2 on 9/25/18 at 3:10 PM, in his room, revealed prior to him receiving his 12:00 PM, dose of [MEDICATION NAME] HCL 20 mg on 9/24/18, his pain level had reached 8 1/2 -to 9. Interview with the Administrator, on 9/25/18 at 1:40 PM, in the conference room, revealed the facility had been conducting an investigation related to a probable medication diversion. Continued interview confirmed an order for [REDACTED]. As a result of the missing medication the resident was 1 day short of pain medication that resulted in him missing 3 doses of his scheduled pain medication. Interview with Licensed Practical Nurse #1 on 9/25/17 at 3:30 PM, in the conference room, confirmed on 9/24/18 at 8:00 AM, resident #2 did not receive his 20 mg [MEDICATION NAME] tablet as ordered. Continued interview confirmed she had mistakenly initialed the medication as given, not as missed. Interview with the Registered Nurse supervisor on 9/25/18 at 3:50 PM, in the conference room confirmed Resident #2, did not receive his scheduled [MEDICATION NAME] HCL 20 mg on 9/24/18 at 12:00 AM, 4:00 AM, and at 8:00 AM and the facility had failed to control Resident #2's pain, and had failed to follow their Medication Administration Policy.",2020-09-01
1099,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2017-09-27,278,D,0,1,TWQI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview the facility failed to accurately complete a Minimum Data Set (MDS) for 2 residents (#89, #47) of 23 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 a quarterly Minimum Data Set ((MDS) dated [DATE] revealed in Activity of Daily Living (ADL) the activity of toileting did not occur. Review of a facility document ADL Record dated (MONTH) (YEAR) revealed Resident #89 was dependent for toileting with two person physical assist. Medical record review of a quarterly MDS dated [DATE] revealed Resident #89 required limited assistance with one person physical assist for eating. Review of a facility document ADL Record dated (MONTH) (YEAR) revealed Resident #89 required supervision with set up only for eating. Observation on 9/27/17 at 7:30 AM, in the dining room revealed Resident #89 was seated at the dining room table, resident awake and alert. The resident's tray was set up by the Certified Nursing Assistant. Further observation revealed Resident #89 cutting his food, and feeding himself with no observed difficulty. Interview with CNA #1 on 9/27/17 at 9:15 AM, on the B wing hall revealed Resident #89 was dependent for toileting during the look back period for the MDS dated [DATE]. Interview with the MDS Coordinator on 9/27/17 at 12:15 PM, in the conference room confirmed the MDS dated [DATE] was coded to reflect the activity of toileting did not occur. Continued interview confirmed the MDS should have been coded dependent with the assist of two for toileting and the MDS dated [DATE] was coded incorrectly for the ADL of toileting. Interview with the MDS Coordinator on 9/27/17 at 12:42 PM, in the conference room confirmed the MDS dated [DATE] was coded to reflect the resident required limited assistance with one person physical assist for eating. Continued interview confirmed the MDS should have been coded supervision with one person assist for eating, and the MDS dated [DATE] was coded incorrectly for eating and reflected a greater decline in the ADL of eating than actually occurred.",2020-09-01
1100,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2017-09-27,332,D,0,1,TWQI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to ensure a medication error rate of less than 5% by administering medications by the wrong route for 1 residnent (#33) of 5 residents observed for medication administration, resulting in a 25% medication error rate. The findings included: Review of the facility policy, Medication Administration General Guidelines dated 8/25/14 revealed, .Medications are administered in accordance with written orders of the attending physician . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report, dated 9/26/17 revealed the following: -Clean peg tube site daily -Acidophilus Capsule (herbal supplement) Give one capsule by mouth two times a day -Aspirin Tablet 325 milligrams (mg) Give 1 tablet by mouth one time a day -[MEDICATION NAME] Tablet (medication for muscle spasms) 10 mg Give 1 tablet by mouth three times a day -Carvedilol Tablet (medication to treat high blood pressure) 12.5 mg Give one tablet by mouth two times a day -[MEDICATION NAME] Capsule (medication for nerve pain) 100 mg Give 1 capsule by mouth three times a day -[MEDICATION NAME] Solution (medication to treat [MEDICAL CONDITION])100mg/ml (milliliters) Give 15 ml by mouth two times a day -[MEDICATION NAME] Solution 10 GM (grams)/15 ml Give 30 ml by mouth one time a day -The above medications were ordered to be administered by mouth. Observation of Licensed Practical Nurse (LPN) #1 on 9/26/17 at 10:30 AM, on the100 hallway revealed LPN #1 prepared and administered medications. Continued observation revealed LPN #1 administered 7 medications through Resident #33's peg tube (tube placed in the stomach for nutrition food and medication) and not by mouth as ordered by the Physician. Interview with the Director of Nursing (DON) on 9/27/17 at 8:42 AM, in the conference room confirmed the facility failed to administer medications as ordered by the physician and failed to follow the facility's policy for medication administration resulting in a medication error rate of greater than 5%.",2020-09-01
1102,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-10-17,604,D,0,1,NOTC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to assess for restraint usage of 1 resident (#47) of 24 residents sampled. The findings include: Review of the facility's Physical Restraints policy dated 8/18/05 revealed .the restraint assessment is completed to ensure the least restrictive device is used and notification is documented; and c. the Physician order [REDACTED]. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #47 had moderate cognition impairment, and required maximum assistance of 2 staff for all activities of daily living except eating, and was non ambulatory. Medical record review of the care plan dated 8/28/18 revealed .broda Chair with Pelvic positioners for positioning. Resident unable to ambulate . Medical record review of the physician's orders [REDACTED].Assistive device: Broda wheelchair with pelvic positioners while out of bed for positioning and enabler for mobility. Resident unable to ambulate . Medical record review of assessments from 1/1/18 to 10/17/18 failed to reveal an assessment to determine if the pelvic positioner was a restraint or not. Observation and interview with the Administrator on 10/17/18 at 9:05 AM in Resident #47's room revealed the resident sitting in a broda wheel chair with padded belts from the front of the chair between his legs, up over both legs and was secured in the back of the chair. Observation revealed the resident was asleep. Interview with the Administrator confirmed the padded belts/pelvic positioner was a restraint due to the resident could not cognitively remove it on command. Observation and interview with Certified Nurse Assistant (CNA) #1 and CNA #2 on 10/17/18 at 2:00 PM, in Resident #47's room revealed the resident sitting in his broda wheelchair with the pelvic positioner. Interview with CNA #1 and CNA #2 revealed the resident cannot undo the belts on command but will occasionally get his leg out from under one of the belts. Observation and interview with Licensed Practical Nurse (LPN) #1 on 10/17/18 at 2:35 PM, in the hallway near the main dining room, revealed the LPN instructed the resident to remove the pelvic positioner, and the resident replied no. Interview with Resident #47 revealed when asked again if he could take it off, the resident repliedno. Interview with LPN #1 confirmed the resident could not remove the pelvic positioner on command. Interview with the Director of Nursing on 10/17/18 at 2:55 PM in the conference room, confirmed Resident #47 had not been assessed to determine if the pelvic positioner was a restraint.",2020-09-01
1103,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-10-17,644,D,0,1,NOTC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview, the facility failed to submit a PASSR (Preadmission Screening and Resident Review) Level II evaluation after completion of a Significant Change Minimum Data Set (MDS) for 1 resident (#55) of 7 residents reviewed for PASSR Level II evaluation. The findings include: Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a PASSR Level I approval evaluation dated 2/6/07. Medical record review of the Significant Change MDS dated [DATE] revealed the facility responded 'no' to the resident having serious mental illness and/or intellectual disability or a related condition. Further review revealed a Brief Interview of Mental Status (BIMS) of '3' indicating severe cognitive impairment and verbal behavior symptoms directed toward others occurred for 1 to 3 days. Interview with the MDS Coordinator on 10/16/18 at 1:45 PM, in the MDS office revealed Resident #55 had cognitive communication deficits, moderate intellectual disabilities, and [MEDICAL CONDITION] .it's been answered wrong the whole time . Interview with the Director of Nursing (DON), the MDS Coordinator, and the Social Service Director (SSD) on 10/17/18 at 1:30 PM, in the SSD office confirmed the MDS Coordinator was responsible for the submission of request of PASSR Level II evaluations. Further interview with the DON confirmed the facility failed to request an evaluation for a PASSR Level II for Resident #55 based on his mental health and mental intellectual diagnoses.",2020-09-01
1104,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-10-17,657,D,0,1,NOTC11,"**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 revise a care plan for pressure ulcers for 1 (#60) resident of 2 residents reviewed for pressure ulcers of 24 residents sampled. The findings included: Review of the facility policy, Skin Care Process, dated 1/17/18 revealed, .Developing and implementing an individualized plan of care .Evaluating the effectiveness of the plan of care and revising approaches as needed . Medical record review revealed Resident #60 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurses Notes dated 10/13/18 revealed .excoriation to buttocks/upper thighs bilat with tx (treatment) in progress . Medical record review of a Anatomical Location Guide dated 10/14/18 revealed open area 6 x 6 back left thigh and open area 6 x 6 back right buttock and upper back of right thigh. Review of the Pressure Injury Report dated 10/14/18 revealed .left upper rear 6 x 6 x 0.1 .current stage 2 .wound bed bright red .MD notified 10/15/18, non-compliant with turning and repositioning .right upper rear 6 x 6 x 0.1 .current stage 2 .wound bed bright red . Medical record review of a Physician's Order dated 10/16/18 revealed .Cleanse buttocks/Peri-area as needed for hygiene, pat dry, use barrier cream post cleaning. (MONTH) apply border gauze for comfort and protection . Medical record review of the care plan dated 9/24/18 revealed the care plan had not been revised to include the pressure ulcers. Observation and interview with the Director of Nursing (DON) on 10/17/18 at 3:50 PM of the resident's buttocks and back of thighs revealed a stage 2 pressure ulcer on the the right lower buttock 6 cm (centimeters) x 6 cm x 0.1 cm, and a stage 2 pressure ulcer on the back of the left upper thigh 5 cm x 4 cm x 0.1 cm as measured and described by the DON. Interview with the Minimum Data Set (MDS) Coordinator on 10/17/18 at 10:55 AM in the MDS office confirmed the care plan had not been revised to include the pressure ulcers.",2020-09-01
1105,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-10-17,686,D,0,1,NOTC11,"**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 document a complete assessment of pressure ulcers and notify the Physician timely for 1 resident (#60) of 2 residents reviewed for pressure ulcers of 24 residents sampled. The findings included: Review of the facility policy, Skin Care Process, dated 1/17/18 revealed, .Registered Nurse .Stages pressure wounds .Observes wounds weekly. (MONTH) be responsible for measuring and documenting the progress of the wound .Licensed Practical Nurse .Provides treatment according to physician's orders .may measure and document progress of wounds if trained and competent in wound evaluation .Documentation should include, but is not limited to, regular skin inspections, pressure wound measurements and progress .when documenting, it is important to include the location of the wound, presence of exudate, pain, signs of infection, and the wound bed characteristics . Medical record review revealed Resident #60 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale dated 9/24/18 revealed a score of 12 indicating the resident was a high risk for skin breakdown. Medical record review of the Daily Skilled Nurses Notes dated 9/27/18 revealed .excoriation to .bilat (bilateral) inner buttocks with treatment in progress . Medical record review of a Physcian's Order dated 9/28/18 revealed .Liquacel or Promod (Protein Supplement) 30ml (milliliters) po (by mouth)daily BID (twice a day) .Renavite (vitamin) 1 tablet po daily .High Protein diet . Medical record review of the Weekly Body Audit dated 10/1/18 revealed .Open areas on back of bilateral thighs . Medical record review of the Nutritional assessment dated [DATE] revealed .Recommendation Double portions of protein to meet protein needs . Medical record review of the Daily Skilled Nurses Notes dated 10/7/18 revealed .Excoriation to bilat inner buttocks with treatment in progress . Medical record review of the Daily Skilled Nurses Notes dated 10/13/18 revealed .excoriation to buttocks/upper thighs bilat with tx (treatment) in progress . Medical record review of a Anatomical Location Guide dated 10/14/18 revealed .open area 6 x 6 back left thigh and open area 6 x 6 back right buttock and upper back of right thigh . Review of the Pressure Injury Report dated 10/14/18 revealed .left upper rear 6 x 6 x 0.1 .current stage 2 .wound bed bright red .MD notified 10/15/18, non-compliant with turning and repositioning .right upper rear 6 x 6 x 0.1 .current stage 2 .wound bed bright red . Medical record review of a Physician's Order dated 10/16/18 revealed .Cleanse buttocks/Peri-area as needed for hygiene, pat dry, use barrier cream post cleaning. (MONTH) apply border gauze for comfort and protection . Interview with the Medical Director on 10/17/18 at 8:30 AM in the conference room revealed the pressure ulcers were unavoidable due to the resident's comorbidities. Interview with the Director of Nursing (DON) on 10/17/18 at 8:40 AM in the DON's office confirmed a complete assessment had not been documented for the open areas on the back of the bilateral thighs on 10/1/18. Continued interview confirmed a complete assessment had not been documented on the stage 2 pressure ulcers on 10/14/18. Interview with the Regional Nurse Consultant on 10/17/18 at 2:00 PM, in the conference room, confirmed no documentation the Physician was notified of the open areas until 10/15/18. Observation and interview with the DON on 10/17/18 at 3:50 PM of the resident's buttocks and back of thighs revealed a stage 2 pressure ulcer on the the right lower buttock 6 cm (centimeters) x 6 cm x 0.1 cm, and a stage 2 pressure ulcer on the back of the left upper thigh 5 cm x 4 cm x 0.1cm as measured and described by the DON.",2020-09-01
1106,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2019-12-04,600,D,1,1,3W9311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 1 resident (#7) of 14 residents reviewed for abuse. The findings include: Review of the facility policy, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed .resident has the right to be free from abuse .Resident's must not be subjected to abuse by anyone .including, but is not limited to .other residents .the facility's goal is to protect the resident from abuse .The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment .and abuse of residents . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed the resident had delusions and had behaviors of wandering. Medical record review of Resident #7's Comprehensive Care Plan revealed .has potential to be verbally aggressive .ineffective coping skills, Mental/Emotional illness, Poor impulse control .potential to be physically aggressive . Medical record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #157's Admission MDS assessment dated [DATE] revealed the resident scored a 0 on the BIMS, indicating the resident had severe cognitive impairment. Further review revealed the resident exhibited verbal and physical behaviors, rejection of care, wandering, and intrusive behaviors daily. Medical record review of Resident #157's Comprehensive Care Plan revealed .behavior problem .reject care, verbal abusive, threatening, screaming, cursing, pushing, hitting, grabbing . wanderer .Impaired safety awareness, resident wanders aimlessly, significantly intrudes . Medical record review of the facility investigation report dated 10/2/19 revealed .found this resident (#157) in floor exchanging contact with another resident (#7) .This resident (#157) was assisted away .a skin tear to left knuckles treated . Medical record review of the facility investigation report witness statement from Registered Nurse (RN) #1 dated 10/2/19 revealed .heard noise in hallway .saw the two residents (Residents #7 and #157) on the floor with one resident hitting the other resident in the face with his fist .separate (separated) them to maintain their safety-the other nurse assisted with keeping residents apart .assessed residents skin for injuries and provided first aid to some skin tears . Medical record review of the Psychiatric Progress note dated 10/7/19, revealed .He (Resident #7) has had a recent resident to resident physical altercation with another resident here. (Resident #7) becomes extremely agitated when someone gets into his personal space .no significant injury to any party . Interview with RN #1 on 12/3/19 at 12:35 PM, in the conference room confirmed Resident #7 was hitting Resident #157 while on the floor and the residents were separated. RN #1 confirmed Resident #157 had a skin tear to the left hand and complained of rib pain. The x-ray was negative for any fractures. RN #1 confirmed Resident #157 had a history of [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/19 at 8:50 AM, in the DON's office, revealed Resident #7 liked personal space and Resident #157 had no concept of personal space. The DON stated .can't always predict behaviors with dementia. I do not believe the incident could have been prevented if staff were in front of them .",2020-09-01
1107,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2019-12-04,657,D,0,1,3W9311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update the care plan to reflect a preference for Do Not Resuscitate status for 1 resident (#40) of 24 residents reviewed for Advanced Directives. The findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED].Do Not Attempt Resuscitation . Medical record review of the current Comprehensive Care Plan revealed .CPR (Cardiopulmonary Resuscitation) . Interview with the Director of Nursing (DON) on [DATE] at 1:54 PM, on the A Hallway, confirmed it was her expectation for .care plans to be updated the next day or the following Monday .if occurred on a weekend .we like to discuss as a team .",2020-09-01
1108,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2019-12-04,677,D,0,1,3W9311,"**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 maintain oral care for 1 resident (#108) of 24 residents reviewed. The findings include: Review of the facility policy, ORAL HYGIENE, revised 8/25/14 revealed .PURPOSE .To cleanse the mouth, teeth, and dentures .To moisten the mucous membranes .Oral hygiene to meet the resident's needs .Inspect mouth and gums for irritation or open areas and notify charge nurse .D[NAME]UMENTATION .Condition of mouth and gums . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nurse's Note dated 11/25/19 revealed the resident was total care for Activities of Daily Living (ADL's). Medical record review of the Admission assessment dated [DATE] revealed Resident #108's skin integrity was normal, had their own teeth, and the tongue, cheeks, and lips were pink. Medical record review of an Electronic Treatment Administration Record dated 11/25/19-12/2/19 revealed oral hygiene was to be completed every shift. Continued review revealed there was no documentation oral care was performed for 9 shifts. Medical record review of an Electronic Medication Administration Record [REDACTED]. Continued review revealed the dry mouth moisturizing solution had been administered two times between 11/25/19 and 12/2/19. Observation and interview with Registered Nurse (RN) #1 on 12/2/19 at 10:45 AM, in the resident's room, revealed Resident #108 was resting in bed. Further observation revealed the resident's mouth was open with dry black debris visible inside the resident's mouth. Continued observation revealed the resident's lips were dry with brown crusted debris. Observation and interview with RN #1 confirmed the resident's diet was by tube feeding and the resident took nothing by mouth. Further interview confirmed the resident should receive regular oral care. Continued interview confirmed Resident #108's mouth was dry with visible black debris and the lips were dry with brown crusted debris. Observation of Resident #108 on 12/3/19 at 7:30 AM, in the resident's room, revealed the resident was resting in bed. Further observation revealed the resident's lips were dry with a small amount of dry dark debris present in the mouth. Interview with the DON on 12/4/19 at 7:30 AM, in the conference room, confirmed her expectations were for staff to complete mouth care every shift and as needed to keep the resident's mouth clean. Observation of Resident #108 on 12/4/19 at 8:25 AM, with the Director of Nursing (DON) in the resident's room, confirmed the resident's mouth had visible dry black debris and dry lips.",2020-09-01
1109,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2019-12-04,693,D,0,1,3W9311,"**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 properly label an enteral feeding for 1 resident (#40) of 2 residents reviewed with an enteral feeding. The findings included: Review of the facility policy, ENTERAL FEEDING, dated (MONTH) 25, 2014, revealed .check the enteral nutrition label against the order .Check the following .Resident name, ID and room number .Type of formula .Date and time formula was prepared .Rate of administration (mL (milliliters)/hour) . Medical record review revealed Resident #40 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 received tube feeding. Medical record review of the Physician's Orders dated 11/24/19 revealed .at bedtime 4 cans of 2 Cal (tube feeding formula) for 12 hr (hour) @ (at) 65ml/hr . Observations in Resident #40's room on 12/2/19 at 10:58 AM, revealed an unlabeled bag of enteral feeding and a bag of clear fluid was infusing through a mechanical pump. Neither bag was labeled with the resident's identification, the rate of infusion, the nurse's initials or the type of fluid. Interview with Registered Nurse (RN) #1 on 12/2/19 at 11:00 AM, in Resident #40 room, confirmed the bag of enteral feeding and the bag of clear fluid was unlabeled, undated, and not timed. Interview with the Director of Nursing (DON) on 12/3/19 at 9:14 AM, in the DON's office, confirmed her expectation was for enteral feeding .to be labeled with initials of who hung the tube feeding with a date and time . Continued interview revealed it was not acceptable for enteral feeding to be unlabeled.",2020-09-01
1110,HENRY COUNTY HEALTHCARE CTR,445224,239 HOSPITAL CIRCLE,PARIS,TN,38242,2019-01-15,698,D,0,1,K10R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to have an order for [REDACTED]. The findings include: The facility's [MEDICAL TREATMENT]: TREATMENT PROT[NAME]OL policy dated 8/19/02 and updated 9/18 documented, Monitor shunt site for thrill and bruit every shift, if absent report to [MEDICAL TREATMENT] clinic . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 11/5/18 documented, .[MEDICAL TREATMENT] 3x (times) weekly - due to [MEDICAL CONDITION] . The progress note dated 10/19/18 at 1:56 AM documented, .[MEDICAL TREATMENT] 3x wkly (weekly) . Review of the admission orders [REDACTED]. The facility was unable to provide documentation of an order for [REDACTED].>Review of the INTERDISCIPLINARY PROGRESS NOTES dated 10/17/18 - 1/14/19 revealed the shunt site was monitored for thrill and bruit on one of two shifts on the following dates: 10/18, 10/20, 10/23, 10/25, 10/27, 10/30, 11/1, 11/4, 11/6, 11/8, 11/10, 11/13, 11/15, 11/17-11/20, 11/22, 11/27-11/29, 12/1-12/4, 12/6-12/8, 12/10, 12/11, 12/13, 12/15-12/18, 12/20-12/23/18 and 1/3/19. There was no documentation the shunt site was monitored for thrill and bruit on either shift on the following dates: 10/19, 10/21, 10/22, 10/24, 10/26, 10/28, 10/29, 10/31, 11/2, 11/3, 11/5, 11/7, 11/9, 11/11, 11/12, 11/14, 11/16, 11/21, 11/24-11/26, 11/30, 12/5, 12/9, 12/12, 12/14, 12/19/18, 1/4/19, 1/5/19 and 1/14/19. Interview with the Director of Nursing (DON) on 1/15/19 at 9:48 AM, at the North nurses station, the DON was asked if the nurses should be monitoring the [MEDICAL TREATMENT] shunt site for the thrill and bruit. The DON stated, They should be. The DON was asked if she could be sure the nurses were monitoring the site if it was not documented. The DON stated, No. Interview with the DON on 1/15/19 at 11:30 AM, in the conference room, the DON was asked if an order should have been written for [MEDICAL TREATMENT]. The DON stated. Yes .",2020-09-01
1111,HENRY COUNTY HEALTHCARE CTR,445224,239 HOSPITAL CIRCLE,PARIS,TN,38242,2019-01-15,812,D,0,1,K10R11,"Based on policy review, observation, and interview, 4 of 20 (Certified Nursing Assistant (CNA) #1, 2, 3, and 4) staff members failed to serve food under sanitary conditions during dining. The findings include: The facility's HAND HYGIENE DURING MEALTIME policy dated 6/05 documented, .All facility staff will maintain infection control procedures during resident mealtimes .5. Passing trays in hallways: If contact is made with the residents saliva, body fluids, resident possessions, physical contact with self or other staff, you must use soap and water before leaving the room, assisting the resident and prior to going on to pass other trays . Dining observations in the West 1 Hall on 1/13/19 beginning at 12:19 PM, revealed CNA #1 delivered a meal tray to Resident #137. She assisted the resident up in bed and adjusted the bed without performing hand hygiene. CNA #1 continued to set up the tray, poured drinks into cups and touched the inner lid of the cup. CNA #1 then performed hand hygiene. CNA #1 delivered a meal tray to Resident #83, adjusted the bed, and continued to set up the tray without performing hand hygiene. Dining observations in the West 2 Hall on 1/13/19 beginning at 12:31 PM, revealed CNA #2 delivered a meal tray to Resident #138, assisted the resident up in bed, adjusted the bed, and continued to set up the meal tray without performing hand hygiene. CNA #2 then performed hand hygiene. CNA #2 delivered a meal tray to Resident #136, adjusted her bed, and continued to set up the meal tray, without performing hand hygiene. CNA #1 delivered a meal tray to Resident #34, assisted the resident up in bed, and continued to set up the meal tray without performing hand hygiene. Observations in Resident #69's room on 1/13/18 at 12:55 PM revealed, CNA #3 picked up a roll with her bare hands and fed Resident #69. Observations in Resident #69's room on 1/14/19 at 8:20 AM, revealed CNA #4 moved a chair and sat to feed Resident #69 without performing hand hygiene. Interview with the Director of Nursing (DON) on 1/15/19 at 10:20 AM, in the Conference Room, the DON was asked what should staff do after assisting residents, adjusting the bed, and touching objects prior to preparing the tray for the resident and serving trays to other residents. The DON stated, Should wash their hands. Interview with the DON on 1/15/19 at 11:50 AM, in the Conference Room, the DON was asked if it was acceptable to touch food with bare hands while feeding a resident. The DON stated, We wouldn't want to touch any food with bare hands.",2020-09-01
1113,HENRY COUNTY HEALTHCARE CTR,445224,239 HOSPITAL CIRCLE,PARIS,TN,38242,2018-02-22,880,D,0,1,KJ2C11,"Based on policy review, observation, and interview, 2 of 7 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to follow infection control measures to prevent the potential spread of infection and cross-contamination while performing blood glucose monitoring and wound care. The findings included: 1. The facility's HAND HYGIENE policy documented, .When to Wash Your Hands .Before touching wounds, changing dressings, obtaining specimen collections and providing catheter care .Before and after the use of gloves, gowns and masks . 2. Observations in the South hallway on 2/21/18 at 10:54 AM, revealed LPN #1 donned gloves, prepared the glucometer, entered Resident #30's room, performed a blood glucose check, walked into the hallway, cleaned the glucometer, removed her gloves and placed them on a rolling cart with the blood glucose monitoring supplies, donned gloves without performing hand hygiene, prepared the glucometer, entered Resident #31's room, performed a blood glucose check, walked into the hallway, cleaned the glucometer, removed the gloves, disposed of both pairs of gloves without performing hand hygiene, then went to the medication cart to record blood glucose results. Observations in Resident #34's room on 2/21/18 at 5:17 PM, revealed LPN #2 applied gloves, removed a soiled dressing, changed gloves, cleansed the wound and applied the dressing. LPN #2 failed to perform hand hygiene between glove changes and during the wound care. Interview with the Director of Nursing (DON) on 2/22/17 at 2:25 PM, in the DON office, the DON was asked if it was acceptable not to perform hand hygiene between glove changes. The DON stated, No .",2020-09-01
1114,HENRY COUNTY HEALTHCARE CTR,445224,239 HOSPITAL CIRCLE,PARIS,TN,38242,2019-11-14,550,D,0,1,FL2411,"Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to knock before entering a resident's room during medication administration. The findings include: 1. The facility's Resident Privacy policy reviewed 6/18 documented, .All residents will be provided personal privacy .All staff will knock on doors before entering or verbally announce presence . 2. Observations in Resident #14's room on 11/13/19 at 4:28 PM, revealed LPN #1 entered Resident #14's room to administer medications without knocking on the door or verbally announcing her presence. LPN #1 performed hand hygiene and then stated, I left my stethoscope. LPN #1 exited the room. At 4: 30 PM, LPN #1 re-entered Resident #14's room without knocking on the door or verbally announcing her presence. 3. Observations in Resident #74's room on 11/14/19 at 9:57 AM, revealed LPN #2 entered Resident #74's room to administer medications without knocking or verbally announcing her presence. Interview with the Assistant Administrator on 11/14/19 at 9:22 AM, in the Dining Room, the Assistant Administrator was asked if staff should knock before entering a resident's room. The Assistant Administrator stated, Staff should knock before entering a resident's room.",2020-09-01
1115,HENRY COUNTY HEALTHCARE CTR,445224,239 HOSPITAL CIRCLE,PARIS,TN,38242,2019-11-14,697,D,0,1,FL2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services for timely reassessment following the administration of pain medication for 1 of 2 (Resident #66) sampled residents reviewed for pain. The findings include: 1. The facility's .Pain Management policy reviewed 5/14 documented, .it is every resident's right to have his or her pain appropriately and aggressively managed. Any report of pain by a resident is considered sufficient evidence to establish pain as a problem/need/nursing diagnosis .Individual Patient's Narcotic Record .The scale of pain 1-10, the type of pain, location, treatment and follow-up for effectiveness .to indicate the level and type of pain when pain medication is administered and when follow up for effectiveness is documented . 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing History and assessment dated [DATE] documented .Pain Assessment .Is the resident complaining or showing signs of pain .Yes .On a scale of 1 to 10 , with 10 being the most pain ever felt, how does the resident rate the pain .7 .location of pain .Left hip .with movement . The Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] 325 MG (milligrams)-5 MG TAB (tablet) ([MEDICATION NAME]/[MEDICATION NAME]) 1 TAB Oral Every Four Hours As Needed for Pain . The (MONTH) 2019 Medication Administration Record (MAR) documented that [MEDICATION NAME]/[MEDICATION NAME] 325 MG-5 MG was administered to Resident #66 and review of the PRN (as needed) Results and Documentation report revealed the reassessments following the administration of the [MEDICATION NAME]/[MEDICATION NAME] were not performed timely on the following dates: a. administered on 10/9/19 at 7:35 PM, reassessed on 10/10/19 at 1:41 AM b. administered on 10/11/19 at 9:20 AM, reassessed on 10/11/19 at 11:49 AM c. administered on 10/12/19 at 7:41 PM, reassessed on 10/12/19 at 11:24 PM d. administered on 10/13/19 at 2:55 PM, reassessed on 10/13/19 at 4:56 PM e. administered on 10/14/19 at 5:42 AM, reassessed on 10/14/19 at 2:47 PM f. administered on 10/14/19 at 10:58 AM, reassessed on 10/14/19 at 2:47 PM g. administered on 10/14/19 at 2:46 PM, reassessed on 10/14/19 at 5:07 PM h. administered on 10/14/19 at 9:57 PM, reassessed on 10/14/19 at 11:49 PM i. administered on 10/15/19 at 9:26 AM, reassessed on 10/15/19 at 2:15 PM j. administered on 10/15/19 at 2:16 PM, reassessed on 10/15/19 at 4:05 PM k. administered on 10/15/19 at 8:37 PM, reassessed on 10/15/19 at 11:27 PM l. administered on 10/16/19 at 6:22 PM, reassessed on 10/16/19 at 11:27 PM m. administered on 10/17/19 at 4:06 AM, reassessed on 10/17/19 at 6:12 AM n. administered on 10/17/19 at 6:39 PM, reassessed on 10/17/19 at 11:03 PM o. administered n 10/18/19 at 8:20 PM, reassessed on 10/19/19 at 2:46 AM p. administered on 10/19/19 at 12:36 AM, reassessed on 10/19/19 at 2:57 AM q. administered on 10/20/19 at 1:40 AM, reassessed on 10/20/19 at 6:49 AM r. administered on 10/20/19 at 6:49 AM, reassessed on 10/20/19 at 11:28 AM s. administered on 10/20/19 at 3:37 PM, reassessed on 10/20/19 at 6:25 PM t. administered on 10/20/19 at 7:47 PM, reassessed on 10/21/19 at 1:39 AM u. administered on 10/21/19 at 7:06 AM, reassessed on 10/21/19 at 9:40 AM v. administered on 10/21/19 at 6:24 PM, reassessed on 10/22/19 at 12:31 AM w. administered on 10/21/19 at 9:41 PM, reassessed on 10/22/19 at 12:31 AM x. administered on 10/22/19 at 1:45 PM, reassessed on 10/22/19 at 4:12 PM y. administered on 10/22/19 at 5:55 PM, reassessed on 10/23/19 at 11:34 AM z. administered on 10/23/19 at 5:57 AM, reassessed on 10/23/19 at 11:34 AM aa. administered on 10/23/19 at 8:59 PM, reassessed on 10/24/19 at 1:48 AM bb. administered on 10/24/19 at 4:24 AM, reassessed on 10/24/19 at 6:40 AM cc. administered on 10/24/19 at 8:39 PM, reassessed on 10/25/19 at 2:01 AM dd. administered on 10/25/19 at 1:31 PM, reassessed on 10/25/19 at 3:47 PM ee. administered on 10/25/19 at 5:20 PM, reassessed on 10/26/19 at 3:36 AM ff. administered on 10/25/19 at 9:35 PM, reassessed on 10/26/19 at 3:36 AM gg. administered on 10/26/19 at 5:56 AM, reassessed on 10/26/19 at 9:55 AM hh. administered on 10/26/19 at 5:42 PM, reassessed on 10/26/19 at 9:41 PM ii. administered on 10/26/19 at 5:57 AM, reassessed on 10/26/19 at 9:51 AM jj. administered on 10/27/19 at 7:25 PM, reassessed on 10/27/19 at 9:27 PM kk. administered on 10/28/19 at 3:22 AM, reassessed on 10/28/19 at 6:12 AM ll. administered on 10/29/19 at 8:41 PM, reassessed on 10/30/19 at 1:20 AM mm. administered on 10/30/19 at 3:44 AM, reassessed on 10/30/19 at 6:04 AM nn. administered on 10/30/19 at 1:36 PM, reassessed on 10/30/19 at 3:22 PM oo. administered on 10/30/19 at 9:24 PM, reassessed on 10/30/19 at 11:31 PM pp. administered on 10/31/19 at 8:01 AM, reassessed on 10/31/19 at 9:51 AM qq. administered on 10/31/19 at 9:04 PM, reassessed on 10/31/19 at 11:15 PM The (MONTH) 2019 MAR documented that [MEDICATION NAME]/[MEDICATION NAME] 325 MG-5 MG was administered to Resident #66 and review of the PRN (as needed) Results and Documentation report revealed the reassessments following the administration of the [MEDICATION NAME]/[MEDICATION NAME] were not performed timely on the following dates: a. administered on 11/1/19 at 10:05 AM, reassessed on 11/1/19 at 1:23 PM b. administered on 11/1/19 at 3:08 PM, reassessed on 11/1/19 at 6:16 PM c. administered on 11/1/19 at 7:24 PM, reassessed on 11/2/19 at 2:23 AM d. administered on 11/1/19 at 11:34 PM, reassessed on 11/2/19 at 2:23 AM e. administered on 11/2/19 at 9:05 AM, reassessed on 11/2/19 at 6:04 PM f. administered on 11/2/19 at 2:38 PM, reassessed on 11/2/19 at 6:04 AM g. administered on 11/2/19 at 7:12 PM, reassessed on 11/3/19 at 3:39 AM h. administered on 11/3/19 at 9:35 AM, reassessed on 11/3/19 at 11:57 AM i. administered on 11/3/19 at 2:37 PM, reassessed on 11/3/19 at 5:55 PM j. administered on 11/3/19 at 8:16 PM, reassessed on 11/4/19 at 1:30 AM k. administered 11/4/19 at 7:58 AM, reassessed on 11/4/19 at 9:42 AM l. administered on 11/4/19 at 4:30 PM, reassessed on 11/4/19 at 6:21 PM m. administered on 11/4/19 at 9:11 PM, reassessed on 11/5/19 at 12:03 AM n. administered on 11/5/19 at 1:42 AM, reassessed on 11/5/19 at 5:21 AM o. administered on 11/5/19 at 6:51 AM, reassessed on 11/5/19 at 10:09 AM p. administered on 11/5/19 at 6:28 PM, reassessed on 11/5/19 at 9:55 PM q. administered on 11/5/19 at 11:06 PM, reassessed on 11/6/19 at 7:04 AM r. administered on 11/6/19 at 11:56 AM, reassessed on 11/6/19 at 2:04 PM s. administered on 11/6/19 at 9:41 PM, reassessed on 11/7/19 at 3:02 AM t. administered on 11/7/19 at 10:53 PM, reassessed on 11/8/19 at 5:47 AM u. administered on 11/9/19 at 8:58 PM, reassessed on 11/9/19 at 11:24 PM v. administered on 11/10/19 at 8:50 PM, reassessed on 11/10/19 at 11:31 PM w. administered on 11/11/19 at 1:52 PM, reassessed on 11/11/19 at 10:22 PM x. administered on 11/11/19 at 10:22 PM, reassessed on 11/12/19 at 1:13 AM y. administered on 11/12/19 at 9:19 AM, reassessed on 11/12/19 at 12:10 PM Observations in Resident #66's room on 11/13/19 at 8:54 AM, revealed the resident eating breakfast and stated, .I have a lot of pain in my back besides my hip . Interview with the Director of Nursing (DON) on 11/14/19 at 1:21 PM, in the Conference Room, the DON was asked how long after pain medication administration should the pain be reassessed. The DON stated, Within an hour. The DON was shown Resident #66's MAR and confirmed the pain reassessment had not been performed in a timely manner.",2020-09-01
1117,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2020-02-12,689,D,1,1,DKEJ11,"**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 an intervention to prevent falls for 2 residents (Residents #3 and #35) of 4 residents reviewed for falls of 27 sampled residents. The findings include: Review of the facility policy titled, Fall Management, reviewed 4/15/2019, showed .The facility must ensure that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.Implement interventions, including adequate supervision and assistive devices, consistent with a resident's.care plan. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's order dated 2/11/2020 showed a one way slide to wheelchair (non-skid pad for wheelchair seat to prevent resident from sliding forward in the wheelchair) for Resident #3. Review of Resident #3's care plan dated [DATE]20 intervention .one way slide to wheelchair. Observation on Cedar hall by the nurse's station on 2/11/2020 at 1:08 PM, showed Resident #3 seated in her wheelchair without a one way slide in the wheelchair. Interview on 2/11/2020 at 1:13 PM, with Licensed Practical Nurse (LPN) #3 on the Cedar hall nurse's station, confirmed the one way slide was a current care plan intervention and was not in use in the resident's wheelchair seat. Interview on 2/11/2020 at 2:15 PM, with the Assistant Director of Nursing confirmed the one way slide should have been in the resident's wheelchair and was a current safety intervention on the resident's care plan. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 10/2/2018 showed the resident was at risk for falls due to gait/balance problems and unaware of safety needs with interventions including one way slide to wheelchair and assist of 2 staff for transfers. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had modified independence for decision making and unclear speech. The resident required extensive assistance of 2 staff members for transfers and the resident had one fall with minor injury during the assessment period. Review of the Order Summary Report Active Orders As Of: 2/11/2020 showed a Physician's order dated 4/22/2018 for a one way slide to the wheelchair and a Physician's order dated 1/30/2020 for assist of 2 staff with transfers. Observation of Resident #35 on 2/11/2020 at 1:06 PM, showed Resident #35's call light was on, Resident #35 was seated in a wheelchair in the room at the bedside, Certified Nursing Assistant (CNA) #2 entered the room and assisted Resident #35 to the toilet from the wheelchair. During an interview and observation of Resident #35's wheelchair on 2/11/2020 at 1:23 PM, CNA #2 confirmed a one way slide was not in the resident's wheel chair. Observation of Resident #35 on 2/11/2020 at 1:30 PM, showed CNA #3 entered the resident's room and assisted the resident from the toilet back to his wheelchair. During an interview and observation of Resident #35's Kardex on 2/11/2020 at 2:04 PM, CNA #2 confirmed she had assisted the resident to the bathroom (assist of 1 staff) and the Kardex stated 2 assist with transfers and the resident was to have a one way slide in the wheelchair. During an interview on 2/12/2020 at 9:05 AM, the Administrator confirmed it is her expectation for the staff to follow care plans to prevent resident falls in the facility.",2020-09-01
1118,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2020-02-12,770,D,0,1,DKEJ11,"**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 laboratory tests as ordered by the physician for 1 resident (Resident #10) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled Diagnostic Services, reviewed 4/15/2019, showed .Ensure that the residents receive laboratory .services as ordered by the attending physician . Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], showed the resident had severe cognitive impairment and had received an antipsychotic medication daily. Review of the Order Summary Report revealed an order dated 3/2/2018 for lipids (a laboratory test that measures cholesterol level) while on [MEDICATION NAME] (also known as quetiapine, an antipsychotic medication) to be obtained every 6 months, and an order dated 9/6/2018 for quetiapine to be administered 2 times daily. Review of the medical record showed no documentation a lipid panel had been obtained for Resident #10. During an interview on 2/12/2020 at 12:51 PM, Registered Nurse (RN) #1 confirmed Resident #10 received [MEDICATION NAME] as ordered, the lipid panel should have been completed on 3/1/2019 and again every 6 months. The laboratory order for a lipid panel had not been obtained for Resident #10 since (YEAR). During an interview on 2/12/2020 at 1:58 PM, the Director of Nursing (DON) confirmed it was her expectation for labs to be obtained per the physician's orders.",2020-09-01
1119,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2020-02-12,842,D,0,1,DKEJ11,"**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 resident (#39) of 32 residents reviewed for medical records. The findings include: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Tennessee Physician order [REDACTED].Resuscitate (CPR) (cardiopulmonary resuscitation) . Review of the physician's orders [REDACTED].Do Not Resuscitate . During an interview on [DATE] at 4:15 PM, with Licensed Practical Nurse (LPN) #2 on [DATE] at 4:15 PM, stated the facility is to verify the code status of residents upon admission or readmission to the facility. This did not happen with Resident #39. During an interview on [DATE] at 4:15 PM, the Director of Nursing (DON) confirmed the physician order [REDACTED]. The resident's medical record was inaccurate.",2020-09-01
1120,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2020-02-12,880,D,0,1,DKEJ11,"**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 follow isolation procedures for 1 resident (Resident #220) of 2 residents reviewed for isolation precautions. The findings include: Review of the facility policy titled, Transmission-based Precautions and Isolation Procedures, dated 1/30/2019, showed .Transmission-based precautions are implemented .to prevent or control infection .Contact Precautions are intended to prevent transmission of infections that are spread by direct .or indirect contact with the resident or environment, and require the use of appropriate PPE (personal protective equipment), including a gown and gloves upon entering .the room . Resident #220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Recap Report, dated 2/1/2020 - 2/29/2020, revealed an order dated 2/3/2020 for contact precautions for a urinary tract infection. Review of the Care Plan dated 2/11/2020 showed the resident had a urinary tract infection with interventions including contact precautions as ordered. Observation of Resident #220's room on 2/10/2020 at 12:08 PM, showed a sign on the door stating contact precautions. Physical Therapy Assistant (PTA) #1 wheeled the resident's roommate into the room in a wheelchair and did not don gloves or gown prior to entering the room. During an interview on 2/10/2020 at 12:09 PM, PTA #1 confirmed Resident #220 was in isolation and a contact isolation sign was on the door stating to apply gloves prior to entering the room and gown if necessary. PTA #1 also confirmed she had not applied gloves prior to entering the room. Observation of Resident #220's room on 2/10/2020 at 12:13 PM, showed Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 entered the room to deliver the residents their lunch trays, LPN #1 and CNA #1 did not don gloves or gowns prior to entering the room, LPN #1 and CNA #1 both assisted Resident #220 to scoot up in the bed by using the bed linens with ungloved hands. During an interview on 2/10/2020 at 12:17 PM, LPN #1 confirmed she was not aware of which resident in the room was in contact isolation and she had not donned gloves or a gown prior to entering the room. During an interview on 2/10/2020 at 12:20 PM, CNA #1 confirmed Resident #220 was in contact isolation and she had not donned gloves or gown prior to entering the room. During an interview on 2/12/2020 at 1:28 PM, the Director of Nursing (DON) confirmed it was her expectation for gloves to be worn when entering the room and gown when in close contact with the resident such as assisting the resident to scoot up in the bed.",2020-09-01
1121,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2019-03-27,644,D,0,1,YS8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the state mental health authority of a new serious mental illness (SMI) [DIAGNOSES REDACTED].#44) of 3 residents reviewed for Level II Pre-Admission Screening and Resident review (PASRR) of 26 residents reviewed. The findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Continued review revealed a [DIAGNOSES REDACTED]. Medical record review of a PASARR Level I assessment dated [DATE] revealed Resident #44 had no [DIAGNOSES REDACTED]. Interview with Social Worker #1 on 3/27/19 at 9:09 AM, in the Social Services Office, confirmed the facility failed to notify the state mental health authority of a new SMI [DIAGNOSES REDACTED].",2020-09-01
1122,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2019-03-27,812,D,0,1,YS8U11,"Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards in 1 resident nourishment refrigerator of 3 resident nourishment refrigerators observed. The findings include: Observation of the resident nourishment refrigerator on 3/27/19 at 8:10 AM, in the Birch Wing medication room, revealed one bowl of soup and one 20 ounce drink. Interview with Registered Nurse #1 on 3/27/19 at 8:10 AM, in the Birch Wing medication room revealed .no, it is not labeled .that's my lunch .no, it's not supposed to be in there . Interview with the Director of Nursing on 3/27/19 at 8:27 AM, in the conference room, confirmed .no, that should not be in there we have a staff refrigerator for that .",2020-09-01
1123,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2018-04-11,637,D,0,1,YN2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a significant change of status Minimum Data Set (MDS) assessment for 1 resident (#122) of 26 residents reviewed. The findings included: Medical record review revealed Resident #122 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact, was always continent of bowel and occasionally incontinent of bladder. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 0 on the BIMS, indicating the resident had severely impaired cognition, was always incontinent of bladder, and was frequently incontinent of bowel. Medical record review revealed no documentation a significant change of status MDS had been completed after the resident's decline in cognition and continence. Interview with the MDS Coordinator, Registered Nurse #5, on 4/10/18, at 1:25 PM, in the MDS office, confirmed a significant change of status had not been completed after the resident's decline in cognition and continence.",2020-09-01
1124,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2018-04-11,880,D,0,1,YN2K11,"Based on facility policy review, observation, and interview, the facility failed to maintain infection control practices during 1 of 3 medication administration observations. The findings included: Review of the facility policy Hand Hygiene, revised 4/1/15, revealed .hand hygiene is generally considered the most important single procedure for preventing nosocomial (healthcare acquired infection) infections .use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations . Observation of medication administration on 4/10/18 at 7:47 AM on the Cedar Wing with Licensed Practical Nurse (LPN) #5 revealed LPN #5 prepared medications for administration at the medication cart parked in the Cedar Wing hallway. Continued observation revealed LPN #5 entered a resident's room, moved the bedside table, raised the head of the bed, administered medications, and exited the resident's room without performing hand hygiene. Further observation revealed upon exiting the resident's room LPN #5 returned to the medication cart, opened the Medication Administration Record [REDACTED]. Interview with LPN #5 on 4/10/18 at 7:50 AM on the Cedar Wing confirmed by not performing proper hand hygiene she failed to maintain infection control practices during medication administration.",2020-09-01
1125,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2019-04-11,812,D,0,1,KS8Y11,"Based on policy review, observation, and interview, the facility failed follow infection control procedures to prevent the potential spread of infection when 1 of 20 (Certified Nursing Assistant (CNA) #1) staff members failed to perform appropriate hand hygiene and placed a dirty plate lid cover on a clean meal cart. The findings include: The facility's Handwashing/Hand Hygiene policy dated 2/18 documented, .Employees must wash their hands .Before and after direct contact with residents . Observations in Resident #96's room on 4/8/19 at 12:20 PM, revealed CNA #1 touched the bottom of Resident #96's sock, performed tray set up, then removed a piece of cornbread out of the wrapper with her bare hands and placed it on the resident's plate without performing hand hygiene. CNA#1 left the room and placed Resident #96's plate cover lid on the food cart with meal trays. that had not been served. Interview with the Director of Nursing (DON) on 4/11/19 at 10:18 AM, in the DON office, the DON was asked if staff should touch the bottom of a resident's sock, perform meal tray set up, take a piece of cornbread out of a wrapper with her bare hands, and place it on the resident's plate. The DON stated, No . The DON was asked should a plate cover lid be taken out of a resident's room and be placed on the food tray cart with meal trays that have not been served. The DON stated, No.",2020-09-01
1126,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,157,D,1,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician of significant changes in a resident's status for 1 of 20 (Resident #87) sampled residents of the 32 residents included in the stage 2 review. The findings included: Closed medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. Confidential QA (Quality Assurance) document - allegation of neglect (Resident #87) (undated) documented, .She stated that around 5:45-6:00 [NAME]M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday Feb (February) 2nd (YEAR) .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87)'s O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP (blood pressure) and it was 90/50. The nurse and I kept talking to (Resident #87) to try to get a response. (Resident #87) did not talk but he nodded his head in response to the nurse and I . Interview with the Director of Nursing (DON) on 5/16/17 at 1:10 PM, in the Break Room, the DON was asked if the physician was notified when the resident became unresponsive in the night. The DON stated, .Not to my knowledge .there was not any documentation of that incident . The DON was asked if there should have been documentation describing the earlier incident with the resident. The DON stated, .oh yes, there should have been . The DON was asked if the family was notified. The DON stated, Not to my knowledge. The DON was asked if she expected her staff to notify the physician when there is a change in status. The DON stated, Yes, the nurse should have notified the doctor. Telephone interview with (Named Physician) on 5/17/17 at 11:47 AM, (Named Physician) was asked if he was familiar with Resident #87. (Named Physician) stated, .I see a lot of residents .I will look at the medical records on my computer . (Named Physician) was asked if the facility notified him of Resident #87's non-responsive episode at 6:00 AM on 2/3/17. (Named Physician) stated, .they will notify me .I don't remember if they did, I get a lot of phone calls . (Named Physician) was asked if he expected for the facility to notify him when a resident becomes non-responsive. (Named Physician) stated, .well sure .I would send them to the emergency room unless maybe they were a DNR (Do not Resuscitate) .",2020-09-01
1127,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,221,D,0,1,7VZO11,"**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 1 of 1 (Resident #49) sampled residents was free from restraints of the 1 resident reviewed with a restraint. This failure placed Resident #49 at risk for physical decline and potential harm. The findings included: 1. The Use of Restraints policy documented, .an evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. Restraints with locking devices shall not be used . 2. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Pre-Restraining Evaluation dated 7/17/14 revealed a lap tray to Resident #49's wheelchair was recommended. The Informed Consent for Use of Restraints, for Resident #49, dated 7/17/14 documented, .I have been informed that an evaluation has been done by the appropriate healthcare professionals to determine the appropriateness of use of restraints and participation in the restraint reduction program . was left blank. The consent also documented, .I understand that I have the right to refuse the use of restraints or can revoke this consent at any time . was left blank, however, the consent was signed by the resident's responsible party. Review of the resident's Physical Restraint Elimination Review dated from 3/9/17 to 3/27/17 revealed on 3/27/14 the staff put a self-releasing alarm lap buddy on Resident #49's wheelchair. The next review dated 4/8/14 the lap buddy was discontinued. On 7/22/14 the self-releasing lap belt was discontinued and a lap tray was ordered. The most recent Physical Restraint Elimination Review, dated 3/9/17, indicated Resident #49 was .not diagnosed as being restrained at this time. The lap tray serves as an enabler . A quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #49 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had severe cognitive impairment, needed extensive assistance with all activities of daily living (ADLs) and a restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body) was not used for Resident #49. The care dated 7/18/14 and revised on 4/27/17 documented, .Focus .potential for complications related to use of lap tray .Interventions .apply lap tray to w/c (wheelchair) when up due to res (resident) leaning abnormal posture and h/x (history of) attempts to stand without assist .check resident and release device every 2 hours and PRN (as needed) for toileting needs, positioning, and exercise. Remove at meals as res tolerates .ensure MD (physician) order for device and consent for use is current and updated as needed .evaluate need and effectiveness of lap tray quarterly and as needed . The physician's orders [REDACTED].apply lap tray for positioning due to leaning forward and safety when up in wheelchair . 3. Observations during initial tour of the facility on 5/15/16 at 9:35 AM, in C hall between room C19 and the storage room, Resident #49 was observed in a wheelchair with a plastic tray attached to both armrests and positioned across her lap. The tray was tilted upward slightly and was belted behind the resident's chair with a clasp. Observations of Resident #49 in the wheelchair restrained by the belted lap tray on 5/16/17 at 12:52 PM in the dining room, on 5/16/17 at 4:10 PM in her room, on 5/17/17 at 7:41 AM in the hallway, and on 5/17/17 at 1:46 PM in her room. Observations of Resident #49 on 5/17/17 at 1:58 PM, in Resident #49's room, the Director of Nursing (DON) asked Resident #49 repeatedly to remove the lap tray. The DON placed the resident's hands on the tray and asked her to push it off. Resident #49 was unable to comply with the request. The DON stated, .at this time that the resident's current level of dementia and decreased strength would not allow her to remove the belted lap tray . During an interview with Licensed Practical Nurse (LPN) #1 on 5/16/17 at 3:33 PM, at C hall nurses station, LPN #1 was asked about the belted lap tray and what was the purpose for its use. LPN #1 stated, .the belted lap tray on Resident #49's wheelchair was used for positioning. LPN #1 also stated, . (she) had suggested to the Interdisciplinary Team (IDT) that a geri (geriatric)-chair for the resident be tried, but it had not been attempted and (she) had not seen the resident try and remove the tray in 3 or 4 months . During an Interview with LPN #3 (MDS Nurse) on 5/16/17 at 5:00 PM, in the MDS office, LPN #3 was asked about the belted lap tray. LPN #3 stated, .(I) thought the belted lap tray was a restraint . During an Interview with the Therapy Coordinator, on 5/17/17 at 8:39 AM, in the therapy room, the Therapy Coordinator was asked about the lap tray. The Therapy Coordinator stated, .(Resident #49) used the chair for several years .recently attempted a scoop chair but it was unsuccessful for the resident, due to her leaning forward . The Therapy Coordinator stated, .utilizing the tray without the clasped belt had never been tried .(named Resident #49) had a decline in her mobility and cognition .she could no longer stand or ambulate on her own . During an Interview with the Director of Nursing (DON) on 5/17/17 at 3:38 PM, in the DON's office, the DON was asked what medical symptom required the lap tray. The DON stated, .I guess the medical symptom would be Alzheimer's . The DON agreed the documentation regarding the lap tray, for Resident #49, did not reflect this. The DON stated, . the restraint consent form should be filled out completely. After reading the facility's policy on restraints, the DON stated, .the term locking device left some questions, I am unsure if the belt clasp was technically a lock .(Named Resident #49) was unable to remove the lap tray and that was in contradiction to their policy. The DON stated, .did not think a restraint should be coded on the resident's MDS because they were using the lap tray as an enabler. When asked what the belted lap tray enabled the resident to do, the DON stated, sit upright . When asked if the resident did in fact sit upright with the lap tray, the DON stated, She does not, but it keeps her from leaning all the way forward . The DON confirmed, they had not attempted to use the lap tray without the belt or to utilize a geri-chair.",2020-09-01
1128,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,241,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to promote dignity and respect for residents by labeling a gerichair with a residents name for 1 of 32 (Resident #7) sampled residents included in the stage 2 review. The findings included: Review of the facility's Resident Rights Protocol for All Nursing Procedures policy revealed, .To provide general guidelines for resident rights .Resident dignity and respect . The medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Observations in Resident #7's room on 5/15/17 at 10:35 AM, and 5/17/17 at 9:09 AM revealed Resident #7's gerichair was labeled with his name, written in ink on top of chair. Interview with the Director of Nursing (DON) on 5/17/17 at 9:09 AM, in Resident #7's room, the DON was asked if it is acceptable for resident's name to be on a gerichair for anyone to see and if this would be a dignity issue. The DON stated, .his name should not be on his chair .",2020-09-01
1130,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,279,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to develop a comprehensive care plan for pressure ulcers for 1 of 12 (Resident #42 ) sampled residents reviewed of the 32 residents included in the Stage 2 review. The findings included: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/21/17 documented, Risk for alteration in skin integrity .treat dry skin with a moisturizer as needed . No wounds or wound treatments were care planned. The Skin Care notes dated 3/13/17, 3/21/17 and 3/28/17 documented a wound to the coccyx area. Review of a physician telephone order dated 3/7/17 documented, Cleanse wd (wound) to coccyx c (with) ns (normal saline) apply Santyl skin oint (ointment) to necrotic tissue et (and) cover c moist saline gauze et borderfoam daily til necrotic tissue resolved. The Treatment Administration Record (TAR) for (MONTH) (YEAR) documented treatments were performed as ordered to a coccyx wound. Interview with the Regional RAI (Resident Assessment Instrument) Director, on 5/17/17 at 10:17 AM, in the Care Plan office, the Regional RAI Director was asked if the pressure ulcer and treatments should have been care planned. The Regional RAI Director stated, There should be a care plan in place and no, I do not see one.",2020-09-01
1131,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,280,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to revise the resident care plan for pressure ulcers and medications for 3 of 12 (Resident #39, 132, and 143) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: 1. The facility's Care Plans - Comprehensive policy documented, .5. Care plans are revised as changes in the resident's condition dictate 2. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #39 received antidepressants for 7 days during the 7 day look back period. Resident #39 did not have a care plan related to administration of antidepressant medication. During an interview with the Resident Assessment Instrument (RAI) Director on 5/17/17 at 3:05 PM, in the MDS office, the Regional RAI Director was asked if the resident should have a care plan related to antidepressant medications. The RAI Director stated, I do not see one . 3. Medical record review revealed Resident #132 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Evaluation Data Sheet dated 4/7/17 revealed Resident #132 returned to the facility with a Stage 2 red open area to coccyx. Review of the 14 day Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #132 was admitted with Pressure Ulcer of Stage 1 or greater, an unhealed pressure ulcer, and 1 Stage 2 Pressure Ulcer with granulation tissue on admission. The Wound History Screen Report dated 04/11/2017 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted (with) .Length/Width/Depth .3.8/2.7/0.2 cm (centimeters) .Thickness/Stage .II (2) .Type of Wound .Pressure .General Comments and Observations .The report revealed resident was a hospital return with the wound noted to site. Review of the care plan dated 7/29/16 with revision on 7/29/16 documented, resident has a reddened area to the buttocks .resident has an area to her left interior aspect of heel . The Wound History Screen Report dated 4/17/17 documented, Location Name Sacrum / Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted .Length/Width/Depth .2.0/4.3/0.10 cm .Thickness/Stage .II (2) .Type of Wound .Pressure .General Comments and Observations .Treatment continues to wound as ordered . The Wound History Screen Report dated 4/24/17 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted (with) .Length/Width/Depth .3.8/2.7/03 cm .Thickness/Stage .II (2) .Type of Wound: Pressure .General Comments and Observations .Wound site has mild amount of Slough to wound bed with treatment changed to adjust to wound needs . The Wound History Screen Report dated 5/1/17 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted .Length/Width/Depth: 3.8/2.7/UTD (unable to determine) cm .Thickness/Stage .III (3) .Type of Wound .Pressure .General Comments and Observations .Use of Santyl effective in removing slough tissue . The facility's wound report documented, .Wound Type: Pressure Report dated 5/14/17 documented Resident #132 had a .Stage III (3) .admitted with on 4/7/17 to her Sacrum/Coccyx .Type .Pressure .Length 4.2 x Width 2.5 x UTD . Observations on 5/17/17 at 11:11 AM, in Resident #132's room revealed, Certified Nursing Assistant (CNA) #5, Treatment Nurse #1, and CNA #6 knocked and entered Resident #132's room, asked for permission to remove dressing to coccyx and sacrum area and assess the wound. CNA #5, #6 and Treatment Nurse #1 entered the bathroom washed their hands and donned gloves. The head of the bed was lowered and Resident #132 turned towards the window on her right side exposing a dressing to Resident #132's Sacrum and Coccyx. The dressing was taken off exposing a wound to the Sacrum/Coccyx appearing to be a Stage III (3) with a moderate amount of serous drainage noted with a slightly yellow wound bed and pink approximated edges with no odor detected. During an interview with the Regional RAI (Resident Assessment Instrument) on 5/17/17 at 10:35 AM, in the MDS/Care Plan Office, the Regional RAI was asked should the care plan for Resident #132 have been updated upon her return hospital return to facility on 4/7 /17 to reflect the Stage 2 Pressure Ulcer that was hospital acquired. The Regional RAI stated, Yes it should have. The Regional RAI was then asked should the care plan have been updated when the pressure ulcer worsened to a Stage III (3) on 5/1/17. The Regional RAI stated, Yes they should have updated it. The care plan was not revised to reflect the Stage II Pressure Ulcer that Resident #132 was admitted with or the worsening of the same to a Stage III Pressure Ulcer. 4. Medical record revealed Resident #143 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The wound history screen report dated 2/21/17 documented, .Location .Left medial knee .Wound .Open .First Observed .2/16/17 .L 2.0x W x 1.0 x D 0.1 cm .Wound .Pressure .Stage II . The Wound History Screen report dated 5/12/17 documented Resident 143 had a stage unstageable to her Left medial knee The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage II to unstageable. The wound history screen report dated 2/21/17 documented, .Location . Right medial knee .Wound .Open .First Observed 2/20/17 .L) 2.0 x (W) 1.0 x (D) 0.1 (cm) .Wound .Pressure .Stage II . The Wound History Screen report dated 5/16/17 documented Resident #143 had a stage unstageable to her Right medial knee. The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage II to unstageable. The wound history screen report dated 3/20/17 documented, .Location .Rt proximal hip .Wound .Open .First Observed 3/16/17 .L 2.0 x W 1.8 x D 0.3 cm .Wound .Pressure . The wound history screen report dated 4/11/17 documented, .Location .Left hip .Wound .Open .First Observed 3/30/17 .L 1.0 x W 1.7 x D UTD cm . Wound .Pressure. The wound history screen report dated 12/15/16 documented, .Location .Sacral .Wound .Open .First Observed 12/14/17 .L 3.5 x W x 1.5 x 0.1 cm .Wound .Pressure .Stage III . The Wound History Screen report dated 5/16/17 documented Resident #143 had a stage IV (4). The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage III to stage IV. The care plan dated 12/15/16 for Resident #143 revealed the care plan did not reflect Resident # 143 additional pressure ulcers to Left medial knee, Right medial knee, Right proximal hip and Left hip. During an interview with the Treatment Nurse #1 on 5/17/17 at 2:32 PM, at the nurses' station A/B, the Treatment Nurse was asked if she was responsible for revising the care plan for pressure ulcers. The Treatment Nurse stated, Yes. The Treatment Nurse was asked if the care plan should be revised to address all of Resident #143's pressure ulcers and should it be updated to reflect the current stage of the pressure ulcers. The Treatment Nurse stated, Yes.",2020-09-01
1132,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,282,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the care plan interventions for insulin and indwelling catheter care for 2 of 12 (Resident #39 and 100) sampled residents reviewed of the 32 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 11/29/16 and revised on 5/4/17 documented, .Diabetes-risk for complications .administer antidiabetic medication as ordered-see MAR (Medication Administration Record) for specific instructions . The Medication Administration Record [REDACTED].ACCU-CHEKS (CHECKS) TWICE DAILY WITH .[MEDICATION NAME] SLIDING SCALE INSULIN .130-180 2u (units) . The MAR for the month of (MONTH) (YEAR) dated 4/18/17 at 5:00 PM documented a blood sugar of 159 and 4 units of [MEDICATION NAME]was administered instead of the 2 units as ordered. The MAR for the month of (MONTH) (YEAR) documented, .[MEDICATION NAME] .INSULIN .INJECT 25 UNITS SUBCUTANEOUSLY TWICE DAILY . The MAR for (MONTH) (YEAR) on 4/29/17 at 5:00 PM did not document Resident #39 received the [MEDICATION NAME]as ordered. The MAR for the month of (MONTH) (YEAR) documented .ACCU-CHECKS (blood glucose testing) TWICE DAILY WITH [MEDICATION NAME] INSULIN PER SLIDING SCALE .131-180=2 UNITS . The MAR for the month of (MONTH) (YEAR) dated 5/6/17 at 5 PM documented a blood sugar of 150 and Resident #39 did not receive the 2 units of [MEDICATION NAME]as ordered. Interview with the Director of Nursing (DON) on 5/17/17 at 2:50 PM,in the DON office, the DON was shown the MARS and she confirmed the insulin was given at the wrong dose or omitted. The DON was asked if the medication should be administered as ordered. The DON stated Yes. 2. Medical record review revealed Resident #100 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/14/16 and revised on 3/7/17 documented, Risk for complications R/T (related to) chronic [MEDICATION NAME], indwelling foley cath (catheter) .treatments as ordered . The physician orders [REDACTED].CATHETER ORDERS .FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT AND AS NEEDED . Review of the Treatment Record (TAR) for the month of (MONTH) (YEAR) did not document catheter care was performed 4/16/17 on the 3/11 and 11/7 shift, on 4/19/17 on the 3/11 shift, and on 4/23/17 for the 7/3, 3/11 and 11/7 shift. Interview with the Director of Nursing (DON) on 5/17/17 at 8:50 AM, at the C-D Nursing station,the DON was asked how often cath care is to be performed. The DON stated,Every shift and prn (as needed). Interview with the DON on 5/17/17 at 8:56 AM, in the breakroom, the DON was asked if catheter care was done should it be documented. The DON stated, Yes ma'am.",2020-09-01
1133,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,315,D,0,1,7VZO11,"**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].#100) sampled residents reviewed with a catheter. The findings included: Medical record review revealed Resident #100 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].CATHETER ORDERS .FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT AND AS NEEDED . Review of the Treatment Record (TAR) for the month of (MONTH) (YEAR) did not document catheter care was performed 4/16/17 on the 3/11 and 11/7 shift, on 4/19/17 on the 3/11 shift, and on 4/23/17 for the 7/3, 3/11 or the 11/7 shift. Interview with the Director of Nursing (DON) on 5/17/17 at 8:50 AM, at the C-D Nursing station, the DON was asked how often catheter care should be performed. The DON stated, .Every shift and prn (as needed) . Interview with the DON on 5/17/17 at 8:56 AM, in the breakroom, the DON was asked when catheter care was done should it be documented. The DON stated, .Yes ma'am .",2020-09-01
1135,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,333,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 of 5 (Resident #39) sampled residents received medications as ordered by the physician. The findings included: 1. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].ACCU-CHEKS (Checks) (blood glucose testing) TWICE DAILY WITH .[MEDICATION NAME] SLIDING SCALE INSULIN 70-130 =0 130-180-=2 u (units) 181-240 =4 u 241-300 =6 u 301-350 =8 u 351-400 =10 u >(greater than) 400 =12u and call MD (Medical Doctor) . The physician orders [REDACTED].[MEDICATION NAME] .INJECT 25 UNITS SUBCUTANEOUSLY TWICE DAILY . The physician orders [REDACTED].=0 UNITS .131-180-=2 UNITS .181-240 =4 UNITS .241-300 =6 UNITS .301-350 =8 UNITS .351-400 =10 units . Review of the Medication Administration Record [REDACTED].ACCU-CHEKS TWICE DAILY WITH .[MEDICATION NAME] SLIDING SCALE INSULIN .130-180 2U (units) . Review of the MAR for the month of (MONTH) (YEAR) dated 4/18/17 at 5:00 PM revealed a blood sugar of 159 and 4 units (u) of [MEDICATION NAME]was administered instead of the 2 units as ordered. Review of the MAR for the month of (MONTH) (YEAR) documented, .[MEDICATION NAME] .INSULIN .INJECT 25 UNITS SUBCUTANEOUSLY TWICE DAILY . Review of the MAR for (MONTH) (YEAR) on 4/29/17 at 5:00 PM Resident #39 did not document Resident #39 received the [MEDICATION NAME]as ordered. Review of the MAR for the month of (MONTH) (YEAR) documented .ACCU-CHECKS TWICE DAILY WITH [MEDICATION NAME] INSULIN PER SLIDING SCALE .131-180=2 UNITS . Review of the MAR for the month of (MONTH) (YEAR) dated 5/6/17 at 5 PM revealed a blood sugar of 150 and there was no documentation Resident #39 received the 2 units of [MEDICATION NAME]as ordered. Interview with the Director of Nursing (DON) on 5/17/17 at 2:50 PM, in the DON office, the DON was shown the MARS and she confirmed the insulin was given at the wrong dose or omitted. The DON was asked if the medication should be administered as ordered. The DON stated .Yes .",2020-09-01
1137,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,441,D,0,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain an environment that was clean and sanitary for 1 of 32 (Resident #7) sampled residents in the stage 2 review and 1 of 4 (Licensed Practical Nurse (LPN) #4) nurses failed to follow infection control measures to prevent the potential spread of infection and cross-contamination during medication pass. The findings included: 1. Review of the facility's Decontaminating and Labeling Equipment policy revealed, .Organic matter must be removed (visible dirt, blood, body fluids, ect.) . The medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Observations in Resident #7's room on 5/15/17 at 10:35 AM, 2:54 PM, 5/16/17 at 7:50 AM, and 5/17/17 at 9:09 AM, revealed Resident #7 was sitting in a geri-chair with the right arm of chair torn with foam exposed, and a brown substance observed under the right arm rest. Interview with the Director of Nursing (DON) on 5/17/17 at 9:09 AM, in the residents room, the DON was asked if the resident's gerichair with right arm torn, foam exposed and brown substance was acceptable. The DON stated, .It looks like dried food, he is a messy eater . The DON was asked if this is acceptable. The DON stated .No, the chair needs repaired . 2. The facility's Handwashing/Hand Hygiene policy documented that hand hygiene should be performed .Before and after direct contact with residents .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . Observations during the medication pass in Resident #25's room on 5/16/2017 at 9:01 AM revealed, Licensed Practical Nurse (LPN) #4 washed her hands, turned the water faucet back on, filled a glass with water, raised Resident #25's bed, then stated, I'm so flustered. I have already washed my hands and I touched everything. LPN #4 exited the room and obtained a stethoscope from the medication cart, applied gloves, stopped Resident #25's feeding, adjusted the resident's gown, checked placement of Percutaneous Endoscopic Gastrostomy (PEG), then administered medications through the PE[NAME] Interview with the DON on 5/17/17 at 11:15 AM, in the DON office, the DON was asked what she expected a nurse to do before administering medications through a PEG tube, if she had touched items in the room. The DON stated, .wash her hands and put on gloves. The DON was asked if it is appropriate to touch equipment and items in the room and administer medications without performing hand hygiene. The DON stated that LPN #4 should have washed her hands.",2020-09-01
1138,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,514,D,1,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the medical record was accurate and complete for documentation of skin, resident change in status, and medications for 3 of 12 (Resident #42, 87,103) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: 1. The facility's Charting and Documentation policy documented, .3. All incidents, accidents, or changes in the resident's condition must be recorded . 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADMISSION EVALUATION DATA sheet dated 3/6/17 documented Resident #42 had a skin tear to the left forearm. The physician's orders [REDACTED].Cleanse S/T (skin tear) to Rt (Right) FA (forearm) . The Treatment Administration Record (TAR) dated 3/7/17 through 3/31/17 documented Resident #42 received a treatment to a skin tear to the right forearm. Interview with Treatment Nurse #1 on 5/17/17 at 2:23 PM, at the C/D hall nurses station, Treatment Nurse #1 was asked if Resident #42 had skin tears on his left arm as indicated on the admission sheet or on the right as indicated on the orders and TAR. Treatment Nurse #1 stated, .all his were on his right. 3. Medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. A Confidential QA (Quality Assurance) document - allegation of neglect of (Named Resident #87) (undated) documented, .The C.N.[NAME] (Certified Nursing Assistant) #3 who cared for the resident on 2/2/17 stated .She stated that around 5:45-6:00 [NAME]M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday [DATE]nd (YEAR) .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87) O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP and it was 90/50. The nurse and I kept talking to (Named Resident #87) to try to get a response. (Named Resident #87) did not talk but he nodded his head in response to the nurse and I . Interview with Director of Nursing (DON) on 5/16/17 at 1:10 PM, in the breakroom, the DON was asked if the physician was notified when the resident became unresponsive in the night. The DON stated, .Not to my knowledge .there was not any documentation of that incident . The DON was asked if there should have been documentation describing the earlier incident with the resident. The DON stated, .oh yes, there should have been . The DON was asked if the family was notified. The DON stated, Not to my knowledge. The DON was asked if she expected her staff to notify the physician when there is a change in status. The DON stated, Yes, the nurse should have notified the doctor. The DON was asked why the facility performed an in-service on abuse. The DON stated, .because the night nurse didn't notify the day shift nurse . The facility failed to provide documentation that Resident #87 was found unresponsive on 2/3/17 approximately 5:45 AM. 4. The facility's Medical Records policy documented, .Appropriate medical/clinical records shall be maintained for each resident .that reflect the day-to-day activities and services/treatment provided to the resident . Medical Record Review revealed Resident #103 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The BEHAVIORAL MEDICINE/PROGRESS NOTE dated 10/24/16, and 11/21/16 documented, .Current Psych Meds: [MEDICATION NAME] 15mg . The physicians orders dated 6/2/16 documented, .D/C (discontinue) [MEDICATION NAME] . Telephone Interview with the Nurse Practitioner (NP) on 5/16/17 at 4:21 PM in the Staffing Coordinator's office, the NP was asked if resident was receiving [MEDICATION NAME]. The NP stated, .I probably just missed it, I can't get my computer to open .I will call you back . The NP returned telephone call on 5/16/17 at 5:30 PM, the NP stated .Yes, I missed it .I will take it off .",2020-09-01
1140,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2019-07-24,760,D,0,1,HMYV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 1 of 3 (Registered Nurse (RN) #1) nurses failed to administer insulin correctly in correlation with meals. RN #1 failed to administer insulin within the proper time frame related to food intake for Resident #21, which resulted in a significant medication error. The findings include: 1. The MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist for typical dosing administration of insulin related to meals documented, .[MEDICATION NAME] .Onset (In hours, unless noted) .15 min (minutes) TYPICAL ADMINISTRATION/COMMENTS .5 minutes prior to meals or immediately after eating . 2. The facility's MEDICATIONS, CHARACTERISTICS OF INSULIN protocol revised (MONTH) 25, 2014 documented, .[MEDICATION NAME] .Onset .0.25 (minutes) . 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Solution .151-200 = (equal sign) 2 units .Before dinner . 4. Observations in Resident #21's room on 7/22/19 at 4:41 PM, revealed RN #1 administered [MEDICATION NAME] 2 units into Resident #21's abdomen. Observations in the Dining Room on 7/22/19 at 5:29 PM, revealed Resident #21 received her meal, 48 minutes after receiving the insulin. 5. Interview with the Director of Nursing (DON) on 7/23/19 at 4:36 PM, in the Conference Room, the DON was asked when should the resident be provided a substantial snack or meal after receiving a [MEDICATION NAME] injection. The DON stated, 30 minutes. The failure of the nurse to provide a meal or substantial snack within 15 minutes of the administration of the [MEDICATION NAME]injection resulted in a significant medication administration error.",2020-09-01
1141,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2019-07-24,761,D,0,1,HMYV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely in 2 of 9 (East Hall Medication Cart and the East Hall Medication Room) medication storage areas. The findings include: 1. Review of the facility's STORAGE OF MEDICATIONS policy dated (MONTH) 5, 2012 documented, .Medication and biologicals are stored safely, securely and properly .Orally administered medication are kept separate from externally used medications .Outdated .medications .are removed from stock . The facility's In Room Medication Cabinets policy dated (MONTH) 5, 2012 documented, .Externally used medications may be stored in the in room cabinet but are maintained in separate containers from oral medications . 2. Observations on 7/22/19 at 9:49 AM, in the East Hall Medication Cart revealed the following: a. 2 open vials of [MEDICATION NAME] with no open date b. 1 open vial of Humalog with no open date c. 1 open vial of [MEDICATION NAME] with no open date d. 1 small bottle of hand sanitizer in the same drawer with a bottle of liquid Vitamin D3, 1 bottle of [MEDICATION NAME] eye drops, 2 bottles of Latanoprost eye drops, and 1 bottle of [MEDICATION NAME] eye drops. e. 121 individual packs of [MEDICATION NAME] in the same compartment with 1 bottle of Antiperspirant, and 2 bottles of odor eliminating spray. f. 1 large bucket of Micro Kill Wipes and 1 Normal Saline syringe i. 4 white elongated pills in an unmarked plastic medication cup. Observations in the East Hall Medication Room on 7/22/19 at 11:35 AM, revealed the following: (1) 1000 milliliter bag of [MEDICATION NAME] Ringer with an expiration date of 5/19. 3. Interview with Licensed Practical Nurse (LPN) #1 on 7/22/19 at 9:55 AM, at the East Hall Medication Cart, LPN #1 was asked what are the 4 white pills in the plastic medication cup. LPN #1 stated, Tylenol. LPN #1 was asked if there should be an unlabeled medication cup with loose pills on the medication cart. LPN #1 stated, No, ma'am. Interview with the Director of Nursing (DON) on 7/22/19 at 3:47 PM, in the Employee Break Room, the DON was asked if internal, external medications, and chemicals should be stored in the same compartment. The DON stated, No. The DON was asked if opened, undated, and expired medications should be stored in the medication storage areas. The DON stated, No.",2020-09-01
1142,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2019-07-24,880,D,0,1,HMYV11,"Based on policy review, observation, and interview, the facility failed to ensure practices were maintained to prevent the potential spread of infection when 1 of 5 (Registered Nurse (RN) #1) nurses failed to perform proper hand hygiene during medication administration observations. The findings include: 1. The facility's HAND HYGIENE policy dated (MONTH) 27, (YEAR) documented, .Dry hands with a clean paper towel .Use a dry paper towel to turn off the faucet . 2. Observations in Resident #39's room on 7/22/19 at 4:08 PM, revealed RN #1 turned off the faucet with his bare hands each time he washed his hands during medication administration. Observations in Resident #21's room on 7/22/19 at 4:28 PM, revealed RN #1 turned off the faucet with his bare hands each time he washed his hands during medication administration. Observations in Resident # 45's room on 7/23/19 at 4:20 PM, revealed RN #1 turned off the faucet with his bare hands each time he washed his hands during medication administration. 3. Interview with the Director of Nursing (DON) on 7/23/19 at 4:36 PM, in the Conference Room, the DON was asked how should nursing staff turn off the faucet after performing hand hygiene. The DON stated, With a dry paper towel. The DON was asked should the nursing staff member turn off the faucet with their bare hands. The DON stated, Absolutely not.",2020-09-01
1143,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,278,D,0,1,8N2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for range of motion for 1 of 16 (Resident #8) sampled residents of the 31 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented Resident #8 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. The quarterly MDS dated [DATE] documented Resident #8 had functional limitations in range of motion with impairment on one side in both upper and lower extremities. The Occupational Therapy (OT) notes dated 9/4/17 documented, .Pt (Patient) agreed to skilled OT intervention. Pt had no s/s (signs/symptoms) of pain or discomfort. Pt tolerated therapeutic stretch to the LUE (left upper extremity) to prepare hand for orthotic splint . Interview with MDS nurse #1 on 9/5/17 at 2:20 PM, in the MDS office, MDS nurse #1 was asked if the admission MDS was accurate. The MDS nurse stated, .It had to be a mistake because he had that contracture on admission .",2020-09-01
1144,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,282,D,0,1,8N2G11,"**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 care plan interventions were followed for a positioning device, providing oxygen (O2) at the correct flow and checking residual of a Percutaneous Endoscopic Gastrostomy (PEG) tube for 2 of 16 (Resident #35 and 81) sampled residents of the 31 included in the stage 2 review. The findings included: 1. The facility's Care Plan-Comprehensive policy documented, .An interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident . 2. Review of Medical record revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/5/17 documented .ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Limited ROM (range of motion), contracture to Right hand, Limited Mobility . Keep abduction pillow between legs at all times .limited physical mobility .Keep abduction pillow between legs at all times .oxygen therapy r/t (related to) SOB, hx (history) of Pneumonia .O2 setting as ordered . Observations on 9/5/17 at 11:35 AM and 4:09 PM, 9/6/17 at 8:39 AM, and 9/7/17 at 8:38 AM and 11:21 AM, revealed an abduction pillow was not in place and the O2 concentrator was set at 2 Liters per minute. Interview with Licensed Practical Nurse (LPN) #1 on 09/07/17 at 11:41 AM, in Resident #35's room, LPN #1 was asked if the resident should have an abduction pillow in place. LPN #1 stated, Yes. LPN #1 was unable to locate an abduction pillow in the room at that time and stated, I will find it . Interview with Licensed Practical Nurse (LPN) #1 on 09/07/17 at 1:58 PM, at the west nurses station, LPN #1 was asked, how many liters of oxygen Resident #35 should be receiving. LPN #1 stated, 3. LPN #1 was asked to verify how many liters Resident #35 was receiving. LPN #1 stated, I don't know who turned this down . 3. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care plan dated 8/7/17 documented, .have a peg tube .check for tube placement and gastric content/residual volume . Review of the Medication Administration Record [REDACTED] a. 8/9/17 2nd (second) shift b. 8/10/17 1st (first) and 2nd shift c. 8/11/17 2nd shift d. 8/12/17 on all shifts e. 8/13/17 on all shifts f. 8/18/17 on 3rd (third) shift Interview with the Director of Nursing (DON) on 9/7/17 at 5:01 PM, in the DON's office, the DON was asked is it was acceptable for the staff to fail to follow the care plan. The DON stated, .No .we should follow the care plan .",2020-09-01
1145,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,309,D,0,1,8N2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure that physician's orders were followed for a positioning device for 1 of 16 (Resident #35) residents of the 31 included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders dated (MONTH) 7, (YEAR) documented, .Patient to wear abductor pillow at all times . Observations on 9/5/17 at 11:35 AM and 4:09 PM, 9/6/17 at 8:39 AM, and 9/7/17 at 8:38 AM and 11:21 AM, revealed an abduction pillow was not in place. Interview with Licensed Practical Nurse (LPN) #1 on 09/07/17 at 11:41 AM, in Resident #35's room, LPN #1 was shown the physicians orders and asked if the resident should have an abduction pillow in place. LPN #1 stated, Yes. LPN #1 was unable to locate an abduction pillow in the room at that time and stated, I will find it . Interview with Director of Clinical Operations (DCO) on 9/8/17 at 8:49 AM, in the Nursing office, the DCO was shown a copy of Resident #35's orders and asked if Resident #35 should have an abduction pillow in place. The DCO stated, Yes .",2020-09-01
1146,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,322,D,0,1,8N2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to follow the physician orders [REDACTED].#81) sampled residents reviewed of the 6 residents with a PEG tube. The findings included: 1. The facility's ENTERAL FEEDING (BOLUS) policy documented, .Check gastric residual volume: 1. Aspirate stomach contents. a. If the stomach content cannot be aspirated, pull back slightly on the tube to reposition. If the tube is still not patent, withhold medication and notify the physician . 2. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had a PEG tube. physician's orders [REDACTED].check for residual every shift. For residual > (greater than)100ml (millimeters), hold the feeding and recheck in one hour. If the residual remains >100ml, continue to hold the feeding and notify the MD (medical doctor). If the residual is Review of the Medication Administration Record [REDACTED] a. 8/9/17 2nd (second) shift b. 8/10/17 1st (first) and 2nd shift c. 8/11/17 2nd shift d. 8/12/17 on all shifts e. 8/13/17 on all shifts f. 8/18/17 on 3rd (third) shift Interview with the Director of Nursing (DON) on 9/7/17 at 5:01 PM, in the DON's office, the DON was asked if it was acceptable for the staff to fail to follow physicians orders. The DON stated, .No .we should follow .physicians orders .",2020-09-01
1147,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,328,D,0,1,8N2G11,"**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 physician orders [REDACTED].#35) sampled residents of the 31 residents included in the stage 2 review. The findings included: 1. The facility's OXYGEN ADMINISTRATION policy documented, .7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 2. Medical record review revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].O2 (oxygen) at 3 liters via (by) nasal cannula continuous every shift for SOB (shortness of breath) . Review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. 3. Observations on 9/5/2017 at 11:35 AM and 4:09 PM, 9/6/17 at 8:39 AM and 9/7/17 at 8:38 AM, revealed the O2 concentrator was set at 2 Liters per minute. 4. Interview with Licensed Practical Nurse (LPN) #1 on 09/07/2017 at 1:58 PM, at the west nurses station, LPN #1 was asked, according to the physicians orders, how many liters of oxygen Resident #35 should be receiving. LPN #1 stated, 3. LPN #1 was asked to verify how many liters of O2 Resident #35 was receiving. LPN #1 stated, I don't know who turned this down . Interview with Director of Clinical Operations (DCO) on 9/8/17 at 8:49 AM, in the Nursing office, the DCO was asked, according to the physicians orders, how many liters of oxygen Resident #35 should be receiving. The DCO #1 stated, 3, The DCO was shown a copy of the (MONTH) MAR indicated [REDACTED]. The DCO verified that the nurse had documented the oxygen was being administered at 2 liters per minute.",2020-09-01
1149,WHITEHAVEN COMMUNITY LIVING CENTER,445233,1076 CHAMBLISS ROAD,MEMPHIS,TN,38116,2017-09-08,441,D,0,1,8N2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 2 of 4 (Certified Nursing Assistant (CNA) #1 and Customer Service Representative) staff members failed to follow infection control practices to prevent the potential spread of infection during dining, and the facility failed to provide proof of health records for 2 of 10 (Licensed Practical Nurse (LPN) #6 and CNA #2) staff personnel files reviewed. The findings included: 1. Review of the facility's Handwashing policy documented, .All personnel shall wash their hands to prevent the spread of infection and disease to other residents, personnel, and visitors. f. before touching, preparing, or serving food . 2. Observations in room [ROOM NUMBER] on 9/5/17 at 12:41 PM, revealed CNA #1 did not perform hand hygiene, removed a tray from the cart, set the tray on the over bed table, touched the straw tip with her bare hands and placed it in the resident's cup. Observations in room [ROOM NUMBER] on 9/5/17 at 12:54 PM, revealed CNA #1 removed a tray from the cart and failed to perform hand hygiene between residents, placed the tray on the over bed table, picked up a urinal off the floor with a paper towel and her bare hands, placed the urinal in the shared bathroom on the floor uncovered, removed a comb and brush from the resident over bed table and placed them in the resident drawer, CNA #1 set the resident tray up touching the resident straw and silverware with her bare hands. CNA #1 failed to perform hand hygiene. Observations in room [ROOM NUMBER] on 9/5/17 at 12:57 PM, revealed CNA #1 failed to perform hand hygiene between residents, set the resident's tray on the over bed table, touched the crank on the bed to adjust the resident up in bed, CNA #1 touched the resident's silverware and straw with her bare hands. CNA#1 failed to perform hand hygiene. Observations in room [ROOM NUMBER]'s shared bathroom on 9/6/17 at 9:02 AM, revealed a dirty t-shirt, pants, a brief and an uncovered urinal lying on the floor. Observations in room [ROOM NUMBER] on 9/7/17 at 8:13 AM, revealed Customer Service representative removed the tray from the cart, set the tray down on the over bed table, touch the crank on the bed adjusted the bed, assisted the resident in an upright position, adjusted the pillow, and failed to perform hand hygiene, completed the tray setup, picked up silverware with her bare hands. Customer Service representative failed to perform hand hygiene. 3. Interview with Resident #81 on 9/6/17 at 8:19 AM, in Resident #81's room, Resident #81 was asked if the clothes in the bathroom belonged to him. The resident stated, .they let my feeding run all on the floor and the bed .I pull them off .I told them I was wet and needed to be changed . The resident was asked when this happened. The resident stated, It happened at 6:30 AM this morning .they still have not changed my sheets . Interview with the Director of Nursing (DON) on 9/7/17 at 3:09 PM, in the DON office, the DON was asked if it was acceptable to have dirty clothing, a brief and a urinal lying on the floor of a shared bathroom. The DON stated, .I would expect them to make rounds every 2 hours and assist with storage of dirty clothing, briefs and the urinal . The DON was asked what is the procedure for hand washing during dining. The DON stated, .Use hand sanitizer between each resident .wash hands if they are visibly soiled .wash hands with soap and water .if they touch the resident .if they touch other items in the residents room .they should wash their hands . The DON was asked if she would expect the staff to wash their hands if they picked up a urinal off the floor with their bare hands. The DON stated, .they should put it up .place it in a plastic bag .wash their hands before continuing with setting up the resident's meal tray . 4. Review of the facility's Health Screening policy documented, .New employees shall complete a health screening prior to beginning work . Review of 10 personnel files on 9/8/17 at 10:00 AM, revealed LPN #6 and CNA #2 did not have completed physical exams. Interview with the LPN #2 the on 9/8/17 at 10:16 AM, in the front office, LPN #2 was asked if the staff members in question had their [MEDICATION NAME] skin test given and resulted or a statement from a physician that she was free from communicable disease. LPN #2 stated, .No .I can't recall if it was read . Interview with the DON 9/8/17 at 10:41 AM, in the DON's office the DON was asked if it was acceptable to not have a physical exam completed for each staff member on hire. The DON stated, .No .we should have them completed .",2020-09-01
1151,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,550,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, observation, and interview, the facility failed to maintain the dignity by ensuring clean clothes were worn daily for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 10/27/17 revealed Resident #2 was not getting clothes changed. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 1 person assistance with dressing. Medical record review of the Annual MDS dated [DATE] revealed Resident #2's BIMS score was 5/15, indicating severe cognitive impairment. Resident #2 exhibited feeling down/depressed for 2-6 days and delusions during the review period. The resident required the same care assistance for ADLs for dressing as in the 11/4/17 assessment. Observation on 3/19/18 at 9:09 AM revealed Resident #2 was in the bed in a gown. Observation at 2:40 PM revealed the resident in bed with clean hair and a clean top. Observation on 3/20/18 at 7:48 AM, 9:30 AM, 11:58 AM and at 5:00 PM revealed Resident #2 was wearing the same top as she was wearing on 3/19/18 at 2:40 PM. Observation on 3/21/18 at 7:50 AM revealed Resident #2 was wearing the same top she was wearing on 3/19/18 at 2:40 PM. Observation at 12:10 PM revealed Resident #2 was in bed with clean hair and wearing a clean top. Interview with the Administrator in the Social Service office on 3/21/18 at 2:15 PM revealed the resident had duplicate clothing items per the CNAs. The Administrator and surveyor went to the resident's room and the top worn, as identified by the surveyor from 3/19/18 at 2:40 PM through 3/21/18 at 7:50 AM, was in a clear plastic bag in the resident's closet . Further observation revealed no duplicate top in the closet as was worn from 3/19/18 to 3/21/18. Further interview with the Administrator confirmed the top in question was not duplicated and was stored in a clear bag in the closet for the family to pick up to do laundry. Further interview confirmed the resident was not in clean clothing on 3/20/18.",2020-09-01
1152,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,558,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, observation, and interview, the facility failed to ensure water was within reach for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 9/13/17 revealed the water was not in reach of Resident #2. The facility actions were to in-service staff immediately to ensure the over bed table was close to the resident and choice of beverage was available. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 had no episodes of [MEDICAL CONDITION], mood, or behavior during the review period. Resident #2 had a delusional psychotic episode during the review period. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 2 person assistance with bed mobility and transfers; extensive 1 person assistance with dressing, toileting, and hygiene; and total dependence with 2 person assistance with bathing. Medical record review of the Annual MDS dated [DATE] revealed Resident #2's BIMS score was 5/15, indicating severe cognitive impairment. Resident #2 exhibited feeling down/depressed for 2-6 days and delusions during the review period. The resident required the same care assistance for ADLs as in the 11/4/17 assessment with the exception of total 2 person assistance for transfers. Observation on 3/19/18 at 12:26 PM revealed Resident #2 in the bed lying on her right side facing the window. Further observation revealed the filled water pitcher and a container of apple juice was on the the over bed table on the door side of the resident therefore it was out of reach of the resident. Observation on 3/20/18 at 7:48 AM revealed Resident #2 in bed lying on her right side facing the window. Further observation revealed the filled water pitcher was on the over bed table on the door side of the resident therefore it was out of reach of the resident. Interview with Licensed Practical Nurse (LPN) #4 on 3/20/18 at 7:50 AM in Resident #2's room confirmed he was assigned to the resident. Further interview confirmed Resident #2's water pitcher was not in reach of the resident. Further interview confirmed the resident was capable of reaching for and drinking from the water pitcher.",2020-09-01
1153,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,561,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, review of the B-Side Showers form, observation, and interview, revealed the facility failed to provide showers as scheduled for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 10/27/17 revealed Resident #2 was not getting showers on scheduled day of shower Monday, Wednesday, and Friday. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 had no episodes of [MEDICAL CONDITION], mood, or behavior during the review period. Resident #2 had a delusional psychotic episode during the review period. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 2 person assistance with bed mobility and transfers; extensive 1 person assistance with dressing, toileting, and hygiene; and total dependence with 2 person assistance with bathing. Review of the B-Side Showers form for (YEAR) revealed Resident #2 was to receive showers on Mondays, Wednesdays, and Fridays during the day shift. Review of the Documentation Survey Report form for Resident #2's Monday/Wednesday/Friday shower on the day shift revealed the following: For 10/2017-There was a total of 13 opportunities for showers. The resident received 1 shower, 6 bed bath, 1 partial bath, and 5 undocumented events. For 11/2017-There was a total of 13 opportunities for showers. The resident received 7 shower, 5 bed bath, 0 partial bath, and 1 undocumented event. For 12/2017-There was a total of 13 opportunities for showers. The resident received 6 shower, 5 bed bath, 1 partial bath, and 1 undocumented event. Medical record review of the nursing notes revealed no documentation in 10/2017 regarding why showers were not provided. Observation on 3/19/18 at 9:09 AM revealed Resident #2 was in the bed in a gown. Observation at 2:40 PM revealed the resident in the bed with clean hair and wearing a clean top. Observation on 3/20/18 at 7:48 AM, 9:30 AM, 11:58 AM and at 5:00 PM revealed Resident #2 wearing the same top as she was wearing on 3/19/18 at 2:40 PM. Observation on 3/21/18 at 7:50 AM revealed Resident #2 wearing the same top she was wearing on 3/19/18 at 2:40 PM. Observation at 2:20 PM revealed Resident #2 was in the bed with clean hair and wearing a clean top. Interview with the Administrator on 3/20/18 at 4:00 PM in the Social Service office revealed during (MONTH) and (MONTH) (YEAR) the facility was using a lot of agency and was in process of training them. Further interview confirmed after reviewing the Documentation Survey Report form for 10/2017 for Resident #2 confirmed .appears no shower as scheduled on Monday, Wednesday, and Friday .",2020-09-01
1154,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,609,D,1,1,NCUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, observation and interview, the facility failed to report an allegation of sexual abuse for Resident #41. The findings include: Facility policy review Freedom of Abuse, Neglect, and Exploitation dated 11/2017 revealed .this facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers staff of other agencies service the resident, family members, legal guardians, friends, or other individuals .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly .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, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law . Facility policy review Resident Rights and Dignity Management dated (MONTH) (YEAR), revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life .Staff to Resident abuse .the facility is responsible for the actions of its employees including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility's policies and procedures . Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident was totally dependent of two or more staff for toilet use and bathing. Continued review revealed the resident was always incontinent of bladder and bowel. Medical record review of Resident #41's comprehensive care plan dated 4/16/16 and revised 5/24/18 revealed .resident is followed by psych (psychiatric) services for [MEDICAL CONDITION], Anxiety Disorder and [MEDICAL CONDITION] with disturbance of mood and behavior . Review of the facility's investigation dated 5/6/19 concerning abuse involving Resident #41 revealed a statement from Certified Nurse Aide (CNA) #4 stating a few months ago Resident #41 alleged she (CNA #4) raped her when she performed perineal care on Resident #41. Continued review revealed the facility suspended CNA #4 related to not reporting the allegation. Continued review of the facility's investigation revealed no reporting to the State Agency of the allegation of rape/sexual abuse for Resident #41. Review of CNA #4's employee file revealed no concerns with abuse education/training. Continued review revealed CNA #4 was not listed on the abuse registry. Continued review revealed CNA #4 had no previous disciplinary actions regarding abuse/abuse reporting. Continued review revealed CNA #4 was suspended on 5/7/19 for failure to report an allegation of rape. Observations and interview with residents during initial tour on 5/13/19 revealed no concerns with abuse/neglect or resident rights. Interviews with various staff on 5/13/19 and 5/14/19 at various times revealed no concerns with abuse/neglect or resident rights. Continued interview with staff revealed no concerns with staff training of abuse/neglect or resident rights or reporting of abuse. Interview with Resident #41 on 5/13/19 at 10:06 AM in her room revealed when asked of reporting to a CNA she was raped, she recalled no incident of rape or being touched inappropriately. Continued interview revealed Resident #41 reported no concerns with abuse; she stated I just wanted the tech to stop drying my ears. Telephone Interview with CNA #4 on 5/14/19 at 4:58 PM she stated a while back maybe 1 and 1/2 months ago when we were doing peri-care (perineal care) on her (Resident #41), she stated we were raping her; I told her we were doing peri-care on her and that was it. Continued interview she stated she (Resident #41) just said 'oh you're raping me', we continued her care and repositioned her and she was fine. Continued interview when asked about training on abuse she stated I was supposed to report it but at the time she (Resident #41) was seeing cats and other things, and there were no cats in her room and I didn't think anything of it; I was suspended and coached for not reporting that the resident stated we raped her. Interview with the Staffing Coordinator on 5/15/19 at 8:28 AM in the dining room revealed CNA #4 was suspended and re-educated on abuse/reporting of abuse, bathing technique, showering and customer service prior to returning to work. Interview with the Director of Nursing on 5/15/19 at 8:40 AM in her office revealed during the investigation of another allegation of staff abuse involving Resident #41, CNA #4 stated Resident #41 had alleged sexual abuse/rape. Continued interview revealed CNA #4 stated the allegation of rape happened months ago (date unknown) while CNA #4 was performing perineal care on Resident #41. Continued interview revealed CNA #4 did not report the allegation to anyone. Continued interview revealed the allegation of sexual abuse was not reported to the state. Continued interview she stated we had no evidence or suspicion this happened and we did not report it to the state; it should have been, we had a lot going on that day. Continued interview revealed any allegation should be reported immediately. Continued interview revealed CNA #4 was suspended and re-educated prior to returning to work. Interview with the Administrator on 5/15/19 at 9:04 AM in her office revealed during the investigation of an allegation of staff to resident abuse involving Resident #41, CNA #4 reported Resident #41 alleged she had been raped. Continued interview revealed CNA #4 stated the allegation of sexual abuse happened months ago and she did not report it. Continued interview revealed CNA #4 was suspended and educated on reporting allegations of abuse. Continued interview confirmed I told her (CNA #4) that any allegation like this was to be reported immediately and I needed to know about it; it should have been reported immediately. Continued interview when asked if this was reported to the state she confirmed no not the rape; when an allegation of sexual abuse is made we would report it within 2 hours and begin an investigation and I did not.",2020-09-01
1155,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,610,D,1,1,NCUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, observation and interview, the facility failed to complete a thorough investigation of an allegation of sexual abuse involving Resident #41. The findings include: Facility policy review Freedom of Abuse, Neglect, and Exploitation dated 11/2017 revealed .this facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers staff of other agencies service the resident, family members, legal guardians, friends, or other individuals All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly . Facility policy review Resident Rights and Dignity Management dated (MONTH) (YEAR), revealed, .the facility is responsible for the actions of its employees including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility's policies and procedures . Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident was totally dependent of two or more staff for toilet use and bathing. Continued review revealed the resident was always incontinent of bladder and bowel. Medical record review of Resident #41's comprehensive care plan dated 4/16/16 and revised 5/24/18 revealed .resident is followed by psych (psychiatric) services for [MEDICAL CONDITION], Anxiety Disorder and [MEDICAL CONDITION] with disturbance of mood and behavior . Review of CNA #4's employee file revealed no concerns with abuse education/training. Continued review revealed CNA #4 was not listed on the abuse registry. Continued review revealed CNA #4 had no previous disciplinary actions regarding abuse/abuse reporting. Continued review revealed CNA #4 was suspended on 5/7/19 for failure to report an allegation of rape. Review of the facility's investigation dated 5/6/19 concerning abuse involving Resident #41 revealed a statement from Certified Nurse Aide (CNA) #4 stating a few months ago Resident #41 alleged she (CNA #4) raped her when she performed perineal care on Resident #41. Continued review revealed the facility suspended CNA #4 related to not reporting the allegation. Continued review of the facility's investigation revealed no reporting to the State Agency of the allegation of rape/sexual abuse for Resident #41. Observations and interview with residents during initial tour on 5/13/19 revealed no concerns with abuse/neglect or resident rights. Interviews with various staff on 5/13/19 and 5/14/19 at various times revealed no concerns with abuse/neglect or resident rights. Continued interview with staff revealed no concerns with staff training of abuse/neglect or resident rights or reporting of abuse. Interview with Resident #41 on 5/13/19 at 10:06 AM revealed when asked of reporting to a Certified Nurse Aide she was raped, she recalled no incident of rape or being touched inappropriately. Continued interview revealed Resident #41 reported no concerns with abuse; she stated I just wanted the tech to stop drying my ears. Telephone Interview with CNA # 4 on 5/14/19 at 4:58 PM she stated a while back maybe 1 and 1/2 months ago when we were doing peri-care (perineal care) on her (Resident #41), she stated we were raping her; I told her we were doing peri-care on her and that was it. Continued interview she stated she (Resident #41) just said 'oh you're raping me', we continued her care and repositioned her and she was fine. Continued interview when asked about training on abuse she stated I was supposed to report it but at the time she (Resident #41) was seeing cats and other things, and there were no cats in her room and I didn't think anything of it; I was suspended and coached for not reporting that the resident stated we raped her. Interview with the Staffing Coordinator on 5/15/19 at 8:28 AM in the dining room revealed CNA #4 was suspended and re-educated on abuse/reporting of abuse, bathing technique, showering and customer service prior to returning to work. Interview with the Director of Nursing on 5/15/19 at 8:40 AM in her office revealed during the investigation of another allegation of staff abuse involving Resident #41, CNA #4 stated Resident #41 had alleged sexual abuse/rape. Continued interview revealed CNA #4 stated the allegation of rape happened months ago (date unknown) while CNA #4 was performing perineal care on Resident #41. Continued interview revealed CNA #4 did not report the allegation to anyone. Continued interview revealed the allegation of sexual abuse was not reported to the state she stated we had no evidence or suspicion this happened and we did not report it to the state; it should have been, we had a lot going on that day. Continued interview revealed any allegation should be reported immediately and an investigation initiated. Continued interview revealed CNA #4 was suspended and re-educated prior to returning to work. Interview with the Administrator on 5/15/19 at 9:04 AM in her office revealed during the an investigation of an allegation of staff to resident abuse involving Resident #41 CNA #4 reported Resident #41 alleged she had been raped. Continued interview revealed CNA #4 stated the allegation of sexual abuse happened months ago and she did not report it. Continued interview revealed CNA #4 was suspended and educated on reporting allegations of abuse. Continued interview she stated I told her (CNA #4) that any allegation like this was to be reported immediately and I needed to know about it; it should have been reported immediately and an ivestigation begun. Continued interview when asked if this was reported to the state and an ivestigation initiated she confirmed no not the rape. Continued interview when asked if Resident #41 was interviewed concerning the incident she cofirmed I did not specifically ask her about the rape, I should have asked her but I didn't; when an allegation of sexual abuse is made we would report it within 2 hours and begin an investigation and I did not.",2020-09-01
1156,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,685,D,0,1,NCUY11,"**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 make an appointment for vision care for 1 resident (#5) of 29 residents reviewed. The findings include: Facility policy review of the Social Services Standard, dated 8/2017, revealed, .It is the standard of this facility to ensure that residents receive proper treatment and assistive devices to maintain vision. All personal needs must be met on a timely basis.The social worker/social service designee is responsible for assisting residents in locating and utilizing any available resources for the provision of the vision services the resident needs . Facility policy review of the Job Description for the Social Services Director (SSD), dated 7/8/18, revealed the duties and responsibilities included making referrals and obtaining services from outside entities. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed an eye exam of Resident #5 on 3/7/19 at 11:20 AM in the facility by the Doctor of Optometry (OD), with 360 Care, for Type 2 DM without complications and bilateral [MEDICAL CONDITION] associated with recent steroid use related to [MEDICAL CONDITION].Results as follows, [MEDICAL CONDITION] are visually significant; Please schedule for cataract evaluation with Ophthalmologist of facility choice. Pt (patient) voiced being ready for surgery and wanting to have [MEDICAL CONDITION] removed . Medical record review of orders for March, April, and (MONTH) 2019 revealed no orders for vision care. Medical record review of Care Plan for Resident #5 dated 5/6/19 revealed .impaired Vision due to [MEDICAL CONDITION] .Interventions include arrange consult with eye care practitioner as required . Medical record review of Progress Notes for Resident #5 revealed no documentation of eye exam on 3/7/19. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate impairment of vision, a Brief Interview of Mental Status (BIMS) score of 15 indicating resident was cognitively intact, required limited assistance for Activities of Daily Living (ADL's) with one person, set-up for meals, and required extensive assistance with personal hygiene. Medical record review of the Quarterly MDS dated [DATE] revealed resident had impaired vision. Observation and interview with Resident #5 on 5/14/19 at 8:23 AM in the resident's room revealed .I have [MEDICAL CONDITION] and I'm waiting for surgery .I can't read or do word puzzle books that I like .I don't go to activities if I need to read or see very well . Further interview revealed the resident did not ask any facility staff about follow-up since the eye exam. Observation during the interview revealed the resident is smiling and talkative. Interview with the Social Services Director (SSD) on 5/14/19 at 8:35 AM in her office revealed she was unaware of the resident's need for cataract surgery and will investigate further. Interview with the SSD on 5/14/19 at 11:00 AM in the conference room revealed the order was not transcribed from the eye exam on 3/7/19 and no surgery had been scheduled. Interview with the SSD on 5/14/19 at 1:30 PM in the conference room revealed an appointment was made for the resident for a consult for cataract surgery on (MONTH) 31, 2019 at 12:30 PM. Interview with the Director of Nursing (DON) on 5/14/19 at 2:40 PM in her office revealed the process for ancillary services in the facility are that the SSD keeps up with routine and as needed appointments for vision care. Further interview revealed the facility has a daily morning and afternoon meeting with administrative staff that includes identifying residents who have ancillary appointments the next day. The SSD receives all results from ancillary services and was responsible for giving them to the Unit Manager or Charge Nurse to place in the resident's chart. Either the SSD, Unit Manager, or Charge Nurse call the Physician and make the appointment for follow-up care as ordered. The family is notified of results of ancillary services at the same time. Continued interview confirmed .she (Resident #5) would not have spoken up and she would not have received vision care as needed . Interview with the SSD on 5/14/19 at 3:30 PM in her office revealed .I received the eye exam report from 3/7/19 for her (Resident #5) today, I had to call for it . Continued interview revealed .I received it on the day of the exam and I usually put it in my notebook where I keep all the ancillary services reports on all the residents; Usually ancillary services will write their orders or tell the Charge Nurse or Unit Manager what they want or they stop in my office and tell me; I am the one who creates the list for the facility that keeps up with all the ancillary services appointments for the residents; I update or review the needs of each resident with them at their Care Plan meetings quarterly; her last Care Plan meeting was 2/27/19; her next will be 6/5/19; her eye exam was on Thursday 3/7/19 so I would have arranged her cataract surgery appointment on 3/8/19 and she could have been seen already; I wish she had said something to me; I don't know when we would have known about this . Interview with the Unit Manager on 5/14/19 at 5:20 PM in the B Hall nurse station revealed that she depends on the SSD to bring her reports of all the ancillary services received by residents so she can call the Physician as needed and put an order in and carry it out. Continued interview revealed .there was no way to access the results of the eye exam since the SSD has the only report . Observation and interview on 5/15/19 at 7:51 AM in the resident's room revealed the resident is smiling and .glad that an appointment has been made . for cataract surgery. Interview with MDS Coordinator on 5/15/19 at 5:20 PM in her office revealed the SSD was responsible for the Section B assessment of vision and should be using a newspaper to assess a resident's vision each time with the same font and lighting. Interview with the SSD on 5/15/19 at 5:35 PM in her office revealed she assessed the resident's vision on the Admission MDS dated [DATE] by having her read a newspaper and confirmed vision was assessed as moderately impaired, also confirmed resident does not wear glasses. Further interview revealed she assessed the resident's vision on the Quarterly MDS dated [DATE] by .asking the resident if her vision was adequate, moderately impaired, or impaired, and she chose impaired . Continued interview revealed .I had to wait for Medicaid approval to schedule her eye exam on 3/7/19 . Interview with the Administrator in her office on 5/15/19 at 5:45 PM confirmed that she would expect an appointment to be made immediately or within 48 hours of ancillary services for any resident, specifically the eye exam on 3/7/19 for her (Resident #5). Continued interview confirmed the follow-up should be done by the nurses or the SSD. Further interview confirmed .the facility will find a new eye doctor for this resident and will try to get an earlier appointment for her cataract surgery since her appointment was delayed due to a lack of follow-up .",2020-09-01
1157,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,812,D,0,1,NCUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, manufacturer recommendations, observations, review of facility work order and interview, the facility failed to maintain 1 of 3 ice machines in a clean and sanitary condition to prevent contamination of the ice and failed to remove foods that are not safe for consumption (expired) in 1 of 2 nutrition rooms and emergency storage. The findings include: Facility policy review, Production, Storage, And Dispensing of Ice, dated ,[DATE] revealed .Ice is prepared, stored and dispensed from clean equipment without contamination from hands or dispensing equipment . Manufacturers' recommendations revealed, .(ice) machines should be cleaned at the very least, twice a year, but the frequency should be increased if . conditions warranty (warrant) additional cleanings . Observation of the ice machine on [DATE] at 12:10 PM in the B Hall Nutrition room in the presence of the Dietary Manager, revealed debris across the inside of the ice bin. Review of the ice machine work order dated [DATE] (for ice machine repair [DATE]) revealed .Drained the bin and cleaned the ice machine and found build up on the inside on the bin and it was cleaned . Interview with the Dietary Manager on [DATE] at 12:10 PM in the B Hall nutrition room when asked would you expect to find any debris on the inside of ice machine, the Dietary Manager stated No. Interview with Administrator on [DATE] at 3:00 PM in her office when asked would you expect to find debris on the inside of a ice machine, she stated .she would not expect to find debris on any ice machine throughout the building . Facility policy review of Food Storage and Labeling on [DATE] dated ,[DATE] revealed, .Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date . Refrigerator Storage .Weekly . Facility policy review of Use and Storage of Food Brought in by Family or Visitors Revised ,[DATE] revealed, .The prepared food must be consumed by the resident within 3 days .If not consumed within 3 days, food will be thrown away by facility staff . Observation of the emergency food supply on [DATE] at 9:15 AM in the emergency supply store room with the Dietary Manager present, revealed the following: ,[DATE] gallon containers of vinegar expired on [DATE] and 1 gallon container of vinegar expired on [DATE]. Further observation of the emergency food supply revealed ,[DATE] pound bags of grits expired on [DATE]. Observation of the B Hall nutrition room on [DATE] at 12:10 PM revealed 1-,[DATE] gallon container of orange juice expired [DATE] and ,[DATE] milliliter (ml) cans of Nepro (nutrition supplement for renal patients) expired ,[DATE]. Interview with the Dietary Manager on [DATE] at 10:15 AM in the dining room when asked if she would expect to find expired foods in the nutrition or storage rooms, stated .I would expect for my staff to use the first in first out method for rotating stock .I would not expect to find any expired foods in any nutrition or storage room . Interview with the Administrator on [DATE] at 3:00 PM in her office when asked would you expect to find expired foods in nutrition or storage rooms, she stated .I would not expect to find expired foods in any nutrition or storage rooms .",2020-09-01
1158,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,225,D,1,1,33I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interview, the facility failed to timely report allegations of abuse for 1 resident (#47) for 35 residents reviewed. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE], readmitted on [DATE], and 1/6/17 with [DIAGNOSES REDACTED]. Review of a facility investigation dated 11/11/16 revealed the following: the date of occurance was 11/8/16 (Tuesday), reported by the Resident to the Social Worker on 11/11/16. The allegation of abuse was reported to the State Agency on 11/18/16 at 3:35 PM by the Administrator. Interview with the Administrator on 7/12/17 at 1:40 PM in the Administrator's office confirmed allegations of abuse reported on 11/11/16 by Resident #47 were not reported to the State Agency until 11/18/16. Continued interview confirmed the facility failed to timely report allegations of abuse.",2020-09-01
1159,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,226,D,0,1,33I011,"Based on facility policy review and interview, the facility failed to implement an abuse policy to include all seven components as required by the Federal Agency. The findings included: Review of facility policy, Abuse Prevention Standard, revised 9/2015 revealed, .The Resident Abuse, Neglect and Misappropriation Prevention Program shall be broken down into the following components for review, training and program implementation: 1. Standard Statement 2. Definitions 3. Abuse Awareness 4. Employment Practices 5. Resident to Resident Abuse 6. Staff to Resident Abuse 7. Reporting/Investigation/Response 8. Prevention through QA (Quality Assurance) . Continued review revealed, .Previously, CMS (Centers for Medicare and Medicaid Services) clarified that 'immediately' means as soon as possible, but should not exceed 24 hours after discovery of the incident .Reporting is not expected to take 24 hours . Further review revealed the policy contained an excerpt from 42.C.F.R. 483.13 (c) (2) which no longer exists in current regulations. Continued review revealed the policy did not address resident exploitation. Interview with the Administrator on 7/12/17 at 1:40 PM in the Administrator's office confirmed the Abuse Prevention Standard policy revised 9/2015 was the current policy. Continued interview confirmed the policy did not contain all 7 components as required by the Federal Agency and did not address exploitation in the policy. The Administrator confirmed the facility failed to maintain and implement an updated facility policy for abuse.",2020-09-01
1160,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,241,D,0,1,33I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain dignity by covering catheters for 1 resident (#42) of 4 residents observed with catheters. The findings included: Medical record review revealed Resident #42 was admitted to the facilty on 4/17/12 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice care on 2/13/17. Observation on 7/10/17 at 12:16 PM in the hallway outside Resident #42's room revealed a catheter bag hanging on the bedframe at the resident's feet with clear yellow liquid in the bag. Observation and interview on 7/10/17 at 3:34 PM with Licenced Practical Nurse (LPN) #2 outside Resident #42's room revealed a catheter bag hanging on the bedframe at the resident's feet with clear yellow liquid in the bag. Further interview with LPN #2 when asked if the facilty was expected to provide privacy covers for catheter bags, the LPN stated yes. Further interview with the LPN confirmed the faclity failed to maintain dignity for Resident #42. Interview on 7/11/17 at 3:00 PM with the Nurse Educator in her office confirmed the staff had been educated and was expected to provide privacy covers for catheter bags. Interview on 7/11/17 at 3:30 PM with the Director of Nursing (DON) in her office confirmed she expected privacy covers to be provided for residents with catheters. The DON confirmed the facility failed to maintain the dignity for Resident #42.",2020-09-01
1161,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,253,D,0,1,33I011,"Based on review of the cleaning schedule for clinical equipment, observation, and interview, the facility failed to maintain a wheelchair in a sanitary manner for 1 resident (#62) of 4 residents with wheelchairs. The findings included: Review of a newly revised cleaning schedule for Clinical Equipment revealed the resident wheelchairs were to be cleaned 7 days a week on the 7:00 PM - 7:00 AM shift. Observation on 7/10/17 at 12:28 PM, 3:44 PM, and 4:28 PM revealed Resident #62 in a wheelchair in various locations in the facility. Observation on 7/11/17 at 7:22 AM in Resident #62's room revealed Resident #62 was in bed and his wheelchair was beside the resident's bed. Further observation revealed the wheelchair frame, the underside of the wheelchair seat cushion, and the seat of the wheelchair had a very heavy accumulation of dried debris. Interview with Licensed Practical Nurse #3 on 7/11/17 at 7:25 AM in Resident #62's room confirmed the wheelchair frame, the underside of the wheelchair cushion, and the wheelchair seat .was dirty . Further interview revealed the 7:00 PM - 7:00 AM Certified Nurse Aides were to clean wheelchairs daily. Interview with the Administrator on 7/11/17 at 7:27 AM in Resident #62's room confirmed the wheelchair was dirty and the facility failed to maintain resident equipment in a sanitary manner.",2020-09-01
1162,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,323,D,0,1,33I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure medications were stored securely for 1 resident (#56) of 35 residents reviewed in Stage I. The findings included: Based on observation of Resident #56 in the resident's room during medication pass on 7/11/17 at 8:20 AM, an unopened tube of DuoNeb (prescription nebulizer medication) was observed on the resident's bedside table. The medication had no pharmacy label and no resident identifiers. Interview with the Unit Coordinator on 7/11/17 at 9:55 AM on the A wing, confirmed the facility policy was not to leave medication unattended in a resident's room and no medication should be left at the bedside unless there is a physician order. Continued interview revealed if there is an order for [REDACTED]. Further interview and record review with the Unit Coordinator confirmed Resident #56 was not one of the residents with a physicians order to keep medication at the bedside. Continued interview with the Unit Coordinator confirmed the facility failed to ensure medications were stored securely for Resident #56.",2020-09-01
1163,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,332,D,0,1,33I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, medication pass observation, and interview, the facility failed to maintain a medication error rate less than 5% for 2 residents (#56, #21) of 8 residents observed during medication pass. 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 medication orders dated 3/25/17 revealed Resident #56 was ordered [MEDICATION NAME] (respiratory medication administered via mask) solution 0.5-2.5 (3) mg (milligrams) /3 ml (milliliters), 3 ml inhale every 12 hours. Observation of Licensed Practical Nurse (LPN) #4 during medication pass observation on 7/11/17 at 8:00 AM on the A wing revealed he went into the room of Resident #56 to administer medications. Continued observation revealed the [MEDICATION NAME] which was due at 8:00 PM 7/10/17 was sitting on the bedside table. Further observation revealed LPN #4 asked the resident if she had done her breathing treatment last night and she said no. Medical record review revealed no assessment for Resident #56 to self-administer medications. Medical record review of the Medication Administration Record [REDACTED]. Interview with LPN #4 confirmed the [MEDICATION NAME] from 7/10/17 was on the resident's bedside table and had not been administered as ordered. Medical record review revealed Resident #21 was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of LPN #4 on 7/11/17 at 12:45 PM at the A hall medication cart revealed the LPN placed Mexsana (a barrier powder for skin excoriation) in a medicine cup without measuring the powder and handed the medicine cup to a Certified Nurse Aide (CNA). Further observation revealed the CNA entered Resident #21's room. Medical record review revealed Physician orders [REDACTED]. Further review revealed the Mexsana Powder was discontinued on 6/9/17. Interview with LPN #4 on 7/11/17 at 2:46 PM at the A hall medicine cart revealed a bottle of Mexsana medicated powder with Resident #21's name on it to be applied every shift. Further interview with LPN #4 confirmed the Mexsana was not on the MAR indicated [REDACTED]. Further interview with LPN #4 confirmed he had given the Mexsana to a CNA to apply on Resident #21. Further interview with LPN #4 revealed .she definitely needs it .I try to go in there and make sure it's done . Interview with the DON on 7/11/17 at 3:30 PM in her office confirmed Mexsana Powder was ordered for Resident #21 on 6/2/17 and was discontinued on 6/9/17. Further interview with the DON confirmed the medication was not on the MAR indicated [REDACTED].",2020-09-01
1165,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,514,D,0,1,33I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reivew and interview, the facility failed to ensure medical records were accurate for 1 resident (#56) of 40 residents reviewed. The findings included: Medical record review of medication orders dated 3/25/17 revealed Resident #56 was ordered [MEDICATION NAME] (respiratory medication administered via mask) solution 0.5-2.5 (3) mg (milligrams) /3 ml (milliliters), 3 ml inhale every 12 hours. Observation of Licensed Practical Nurse (LPN) #4 during medication pass observation on 7/11/17 at 8:00 AM on the A wing revealed he went into the room of Resident #56 to administer medications. Continued observation revealed the [MEDICATION NAME] which was due at 8:00 PM 7/10/17 was sitting on the bedside table. Further observation revealed LPN #4 asked the resident if she had done her breathing treatment last night and she said no. Medical record review revealed no assessment for Resident #56 to self-administer medications. Medical record review of the Medication Administration Record [REDACTED]. Interview with LPN #4 confirmed the [MEDICATION NAME] from 7/10/17 was on the resident's bedside table; had not been administered as ordered; and the facility failed to maintain an accurate medical record",2020-09-01
1166,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-08-22,758,D,0,1,6R5Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide a duration for the use of PRN (as needed) [MEDICAL CONDITION] (chemical substance that alters perception, mood, consciousness, cognition or behavior) medication for 1 (#20) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, Behavior Management, revised 11/2017 revealed, .PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Medical record review of Physician Orders dated (MONTH) (YEAR) revealed an order dated 4/18/18 for .[MEDICATION NAME] (antianxiety medication) 1mg (milligram) every 8 hours as needed for anxiety . Medical record review of Consultant Pharmacist Recommendation to Physician dated 5/6/18 for Resident #20 revealed .discontinue PRN use of [MEDICATION NAME] on or before 14 days of use Continued review revealed a recommendation from the Pharmacist was declined by the Physician on 5/28/18 and he documented patient needs PRN at times otherwise she would be anxious too much most days . Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 8/22/18 in her office at 12:50 PM confirmed she knew PRN [MEDICAL CONDITION] medications were to have a stop date of 14 days or the resident reevaluated for continuation of medication. Further interview the DON stated, The physician had not reevaluated the resident for continued duration of [MEDICATION NAME] since 5/6/18 and the physician wanted [MEDICATION NAME] prn to be indefinite. Further interview revealed the DON confirmed the facility failed to ensure a duration or stop date for the use of PRN [MEDICATION NAME] for Resident #20.",2020-09-01
1167,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-08-22,880,D,0,1,6R5Q11,"**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 provide a sanitary environment to help prevent the development and transmission of infection for 1 (#49) of 2 residents reviewed with indwelling urinary catheters. The findings include: Review of the facility policy, Incontinence Management, revised in 2013 revealed .Objective .to promote hygiene, and reduce migration of infectious organisms to the bladder . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed indwelling catheter related to worsening of wound. Medical record review revealed physicians order dated 6/5/18 for Foley Catheter 16 French (catheter size) for stage 3 pressure ulcer. Medical record review revealed care plan dated 7/26/18 for indwelling catheter for worsening of wounds. Observations of Resident #49 on 8/20/18 at 11:20 AM and 12:13 PM, 8/21/18 at 7:50 AM and 8/22/18 at 6:57 AM in his room revealed Resident #49 was lying in bed with catheter bag attached to bed frame lying on the floor. Interview with the Infection Control Nurse on 8/22/18 outside of resident #49's room at 7:05 AM confirmed the urinary catheter bag lying on the floor was unacceptable to prevent migration of infectious microorganisms to the bladder.",2020-09-01
1168,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2020-02-12,677,D,0,1,QX9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of facility policies and procedures, the facility failed to ensure 2 of 50 sampled residents (Resident #5 and Resident #16) received showers according to their schedules and preferences. Failure to maintain residents' hygiene has the potential to negatively affect the health of residents in the facility. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] according to the Admission Record tab located in Resident #5's Electronic Medical Record (EMR). The record review further revealed Resident #5's [DIAGNOSES REDACTED]. In addition, the Tasks tab of Resident #5's EMR revealed the resident had not received a shower or a bath from 1/14/20 to 2/11/20. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 1/30/20, documented a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating Resident #5 had a severe cognitive impairment. In addition, the MDS indicated Resident #5 required total assistance with bathing. Review of Resident #5's Care Plan dated 1/28/20, located under the Care Plan tab of her EMR, documented, Resident needs assist with activities of daily living (ADLs) related to weakness and unaware of safety needs. In addition, the care plan instructed facility staff to, Offer assistance to resident for toileting, bathing, oral care, dressing needs and oral care. The care plan did not document how frequently the resident preferred bathing. On 2/10/20 at 11:24 AM, Resident #5 was observed sitting in a wheelchair in the Activity Room of the C unit of the facility. Resident #5 appeared unkept and wearing pajamas and house shoes. Resident #5's hair was observed as disheveled and uncombed. In addition, Resident #5's fingernails were observed as dirty and untrimmed. Review of a facility document titled, Shower Schedule, not dated, indicated Resident #5 was scheduled to receive a bath or shower 3 times per week on Tuesdays, Thursdays, and Saturdays during the times of 3:00 PM to 11:00 PM. On 2/11/20 at 3:00 PM, an interview was conducted with the Registered Nurse (RN) #59. RN #59 stated Certified Nursing Assistants (CNA) were responsible for ensuring residents received showers according to their scheduled times. RN #59 further stated the CNAs were required to document the showers in the Shower Book, located at the nurse's station. The Shower Book contained Attestation of Shower Task Completion forms for each resident needing assistance with bathing or showering. Review of the Shower Book, located at the C unit nurse's station revealed 3 Attestation of Shower Task Completion forms were documented for Resident #5 from 1/14/20 to 2/11/20. A review of the forms revealed documentation for 1/28/20, 2/1/20, and 2/6/20. The form dated 1/28/20 documented Resident #5 did not receive a shower at the scheduled time. In addition, the attestation form dated 1/28/20 did not provide an explanation for why the resident did not receive the shower and there was no evidence the attestation form was reviewed by a registered nurse or the unit manager. A review of the attestation form dated 2/1/20 documented Resident #5 did not receive a shower because the resident refused to be showered at the scheduled time. A review of the attestation form dated 2/6/20 revealed Resident #5 received a shower during the scheduled shift. There was no additional evidence provided to indicate Resident #5 was offered or provided showers for the period between 1/14/20 and 2/11/20. On 2/12/20 at 4:30 PM, an interview was conducted with CNA #40. CNA #40 stated she worked on the C unit of the facility and was familiar with Resident #5. CNA #40 stated the Attestation of Shower Task Completion forms were filled out for each resident and signed by the registered nurse on the unit when showers were completed. CNA #40 confirmed there was only 1 of 13 opportunities documenting Resident #5 received a shower during the period between 1/14/20 and 2/11/20 and no additional documentation evidence related to whether Resident #5 had received showers during the last 30 days. On 2/12/20 at 4:30 PM, an interview was conducted with Registered Nurse (RN) #15. RN #15 confirmed there was only 1 of 13 opportunities documenting Resident #5 received a shower during the period between 1/14/20 and 2/11/20 and no additional documentation evidence related to whether Resident #5 had received showers during the last 30 days. 2. An interview on 2/10/20 at 5:03 PM. with Resident #16, in her room, revealed that she only gets about one shower per week and should get three. She alleges it is due to no one to help her stand in the shower as her right leg is weak. Review of the care plan revealed: Resident #16 has an activity of daily living (ADL) Self Care Performance Deficit related to a missing right hip joint; Interventions include but not limited to: Requires extensive assist with bathing. An interview on 2/11/20 at 2:25 PM in Hall B with Certified Nursing Assistant (CNA) # 39, revealed that she does not perform resident #16's bathing on the day shift. She stated that resident #16 has been on an evening bathing schedule. She revealed that the only reason to not give a resident a bath would be a resident refusal per their rights. She stated that about 3 months ago the facility was performing water maintenance and the water was not warm enough that day for showers, this has only happened once. An interview on 2/11/20 at 2:40 PM in Hall B with CNA #26, revealed that she usually works on another hall (Hall C) and fills in for Hall B as needed. She stated the only reason to not give a resident a bath as scheduled is a resident refusal, which would be documented appropriately. She stated that resident #16 is on a Monday and Friday bathing schedule per resident #16's request and recently went to the day shift bathing schedule. She did give resident #16 a bed bath today, resident #16 was very appreciative and told CNA #26 that she was not getting her regularly scheduled showers. CNA #26 stated that resident #16 did not remember her from earlier today or last week when she worked with resident #16. She stated that resident #16 is forgetful. An interview on 2/11/20 in Hall B at 2:55 PM with CNA #71, revealed that she has worked here eight months. She works Friday, Saturday, and Sunday only. She has given resident #16 a shower every Friday that she worked as it is the only day that resident #16 is scheduled for bathing on her shifts. Resident #16 will usually get a shower but will get a bed bath occasionally. She stated that resident #16 requires extensive assistance for showering. The Hoyer lift is used to move resident #16 from the bed/chair to the shower chair. Resident #16 had not complained of not getting showers. The bathing documentation by the CNA is recorded on a shower sheet that is kept behind the nurse's station. This surveyor asked to see the sheets. An interview on 2/12/20 at 9:00 AM in Hall B with Unit Manager (UM) #59 revealed that the expectation for resident's showers is that they get all of their scheduled showers. The only reason to miss a shower is resident refusal or emergency situations. Resident #16 was changed from evening shift bathing to day shift bathing schedule last week. The shower schedule was changed to day shift for Mondays and Fridays, per resident request. Review of the Shower Sheets for this year revealed that resident #16 was given showers on 1/10/20, 1/24/20, 1/27/20, 1/31/20, 2/7/20. The resident should have received showers on 1/1/20, 1/3/20, 1/6/20, 1/8/20, 1/10/20, 1/13/20, 1/15/20, 1/17/20, 1/20/20, 1/22/20, 1/24/20, 1/27/20, 1/29/20, 1/31/20, 2/3/20, 2/7/20, and 2/10/20. Resident #16 only received five of 17 showers scheduled. Review of the facility policy titled, Quality of Life - Resident Self Determination and Participation, dated revised 2/2020, stated, Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: .(b) Personal care needs, such as bathing methods, grooming styles and dress.",2020-09-01
1169,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2020-02-12,679,D,0,1,QX9O11,"Based on observation, document review, and staff interview, the facility failed to provide meaningful activities for one (Resident #21) of 6 residents sampled on the Behavioral Health Unit. The facility's failure to provide meaningful activities could result in a diminished quality of life for Resident #21. Finding include: Observation of residents on the Behavioral Health Unit on 2/10/20 at 11:30 AM revealed the TV was on and no residents were attending the movie. Observation of the residents on the Behavioral Health Unit on 2/10/20 at 12:30 PM revealed Resident #21 seated in wheeled recliner at the nurses station with a radio playing. The activity list posted on a white board near the activity/dining room door states that music therapy was to be provided. Interview with Licensed Practical Nurse (LPN) #33 at 2/10/20 at 1:00 PM revealed the music therapy was listening to the radio the staff turn on for the residents and stated was uncertain if the music was residents' preference. LPN #33 stated that the activities listed on the white board were not scheduled activities, but activities the staff could conduct with residents. Observation of Resident #21 on the Behavioral Health Unit on 2/11/20 at 11:30 AM revealed the residents in the dining room/common area. There was a western movie on TV with two residents looking towards the TV intermittently and Resident #21 not watching the TV. A Nursing Assistant was trimming another resident's fingernails at the table near the TV. Interview on 2/11/20, in the activity/dining room, with Activity Director #12 confirmed watching the movie on TV was not an engaging activity for the residents, including Resident #21. Activity Director #12 stated provision of personal care including nail clipping in the dining/activity with other residents present was not appropriate. When asked about the activity, Activity Director #12 stated the goal of the activity was to entertain and contain the residents prior to lunch service. Interview with Social Services Director #14 on 2/12/20 at 9:00 AM in the main dining room revealed residents on the Behavior Health Unit may include in the facility activities as well as the activities on the Behavioral Health Unit, but there is sometimes they do not attend.",2020-09-01
1170,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2020-02-12,710,D,0,1,QX9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and review of facility policies, the facility failed to obtain physician orders for 2 residents (Residents #152 and Resident #301) out of a survey sample of 2 residents selected for [MEDICAL CONDITION] (trach) care. Failure to obtain a physician's order prior to services may cause a resident to receive services without medical necessity. Findings include: 1. Review of Resident #152's hospital report Physician Orders, dated 1/27/20, revealed the resident had a indwelling urinary catheter in place for [MEDICAL CONDITION] bladder. The hospital records did not indicate the size of the catheter tubing, balloon size, or identified what care was to be rendered to the catheter. The hospital physician orders revealed the resident was on oxygen via single-lumen cannula to his trach. There was no rate indicated for the oxygen. Review of Resident #152's facility medical record under the Admission Record, identified the resident was admitted to the facility 1/30/20, with a [DIAGNOSES REDACTED]. Review of Resident #152's Baseline Care Plan, dated 1/31/20, indicated the resident was to [MEDICAL CONDITION], suctioning, and oxygen therapy. Review of Resident #152's physician Order Summary Report, dated 2/11/20, failed to have physician orders that addressed the administration of oxygen,[MEDICAL CONDITION] and suctioning, and catheter tubing and balloon size, and care required for the use of the catheter. During an observation conducted on 2/10/20 at 3:08 PM, Resident #152 was observed in his room, in bed, with the head of his bed raised to approximately 30 degrees. A catheter bag was observed to hang on the side of his bed, which faced the entrance to the room. The resident had [MEDICAL CONDITION] that was secured over the resident'[MEDICAL CONDITION]. Oxygen tubing was attached to this mask and delivered oxygen to the resident. The oxygen compressor was next to the resident's bed and read three liters. A suction machine was also observed on the resident's side table. An attempt was made to interview the resident during this observation and the resident did not respond to yes or no questions. During an interview on 2/11/20 at 11:42 AM, Licensed Practical Nurse (LPN) #33 stated when a resident was newly admitted she would look through the physician orders to identify the care the resident required. If there were no physician orders, she would notify the physician to obtain orders so there would be no lapse in care. During an interview on 2/11/20 at 3:11 PM, Registered Nurse (RN) #59 confirmed she was the staff member who transcribed hospital orders to facility orders for a newly admitted resident. RN #59 reviewed the Electronic Medical Records (EMR) for Resident #152 and confirmed there was no catheter order for tubing, balloon size, and care, there was no physician's order [MEDICAL CONDITION] or suctioning, and there was no order for the administration of oxygen. RN #59 stated she would normally call and clarify all physician orders. RN #59 then entered Resident #152's room and looked at the oxygen compressor and stated the compressor was set at 3.5 liters. During an interview on 2/12/20 at 8:34 AM, the Medical Records Coordinator, stated the hospital physician orders needed to be transcribed into the facility's EMR, when a resident was newly admitted . During an interview on 2/12/20 at 3:56 PM, conducted while in the Administrator's office with the Administrator present, the Director of Nursing (DON), confirmed the transcribed physician orders for Resident #152 were in the EMR, but in que. When in que, orders could not be seen by the nursing staff. The DON stated the physician orders were not activated until the day before (2/11/20) by the facility. Review of a facility policy titled, Medication and Treatment Orders, dated as revised 2/20, revealed, .Orders for medications and treatments will be consistent with principles of usage and effective order writing.A current list of orders must be maintained in the clinical record of each resident.Oxygen orders.When recording orders for oxygen, specify the rate of flow, route and rationale.Treatment Orders.When recording treatment orders, specify the treatment, frequency. Review of a facility policy titled, Catheter Care, Urinary, dated as revised 2/20, failed to address the need for physician orders on catheter tubing size, size of balloon, and care and treatment required for the use of a catheter, such as when to change tubing and catheter bag. Review of a facility policy titled, Oxygen Administration, revised 1/20, indicated, .Verify that there is a physician's order for this procedure. 2. Resident #301 was transferred from an out of state facility. He has been in this facility for seven days as of 02/10/20. He has a [MEDICAL CONDITION] (trach) (a cut into a person's neck, below the vocal cords, to place a tube into the windpipe allowing air into the lungs) with oxygen (02) administration via tubing. Review of the Treatment Administration Record (TAR) for Resident #301 revealed the first [MEDICAL CONDITION] was provided for resident #301 on 2/11/20. A review of the admission orders [REDACTED]. A review of the current orders on 2/10/20 at 11:00 AM revealed no orders since the day of admission (seven days ago) in the Electronic Medical Record (EMR) system under Physician's Order tab on 2/11/20 for orders [MEDICAL CONDITION], 02 administration, nor 02 settings. The staff was not able to provide documentation of any orders prior to 2/11/20. The Director of Nursing (DON) provided documentation of a generic order, without a resident name, for [MEDICAL CONDITION] care. Interview on 2/12/20 at 8:45 AM in room [ROOM NUMBER] with Licensed Practical Nurse (LPN) #17, revealed that she was trained by the Respiratory Therapist (RT) #74 how the set up [MEDICAL CONDITION] to the proper 02 settings. The order for 02 is given in a percentage number on the orders, there is a dial in [MEDICAL CONDITION] to set the 02 for the correct percent of flow. An interview on 2/12/20 at 9:00 AM in Hall B with Unit Manager (UM) #59, revealed there should be orders from the transferring facility upon arrival since Resident #301 arrived with [MEDICAL CONDITION] 02 in place. UM #59 verified there were no orders for Resident #301 [MEDICAL CONDITION], 02 administration, nor 02 settings in the medical record. Interview on 2/12/20 at 11:30 AM in Hall B nurse's station with LPN #10, revealed Resident #301 has been here about 1 week. The Respiratory Therapist (RT) came in earlier the day of arrival to set up [MEDICAL CONDITION] 02 machine. When resident #301 arrived, she only had to attach the tubing to [MEDICAL CONDITION] turn the machine on. Resident #301 arrived at about 6:15 PM, she left at 7:00 PM, (the end of her shift). The RT was not present at the time resident #301's arrived and did not come in by the time she left at 7:00 PM. She does not remember seeing an order for [REDACTED].#10 stated, he has been [MEDICAL CONDITION] and 02 therapy since admission seven days ago. Review of the facility's policy titled [MEDICAL CONDITION] Care, last revised 1/2020, revealed the purpose of this procedure is to guide [MEDICAL CONDITION] care and the cleaning of reusable [MEDICAL CONDITION] cannulas. General guideline #10. Document the procedure, condition of the site, and the resident's response. Review of the facility's policy titled Oxygen Administration, last revised 1/2020, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. Further review revealed under Preparation 1. verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.",2020-09-01
1174,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2019-02-21,584,D,0,1,GXQE11,"**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 provide a safe, clean and sanitary environment for 1 resident (#48) of 65 residents reviewed. The findings include: Facility policy review, Infection Control Standard, revised 11/2017 revealed .Standards and procedures have been established for routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling. Personnel are trained in the use of the procedures . Medical record review revealed Resident #48 was admitted on [DATE] and a readmission on 1/9/18 with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #48 required total dependence for transfers with assistance of two staff members. Observation on 2/19/19 at 8:45 AM and 9:00 AM in Resident #48's bathroom, revealed a bedpan sitting on a handrail unbagged, urine in the commode, toilet paper on the floor, and four washbasins stacked on the floor. Further observation revealed a soiled dressing on the floor near the dresser, and a large hole approximately 8 inches in the foot board exposing particle board and jagged edges. Interview with Resident #48 on 2/19/19 at 8:45 AM in Resident #48's room revealed .I haven't been out of bed in two weeks . Interview with the Director of Nursing on 2/21/19 at 7:58 AM in her office confirmed .the bath pan, soiled wound dressing, and soiled toilet paper should not have been on the floor . Further interview confirmed .the bed pan should have been bagged and urine should not have been left in commode . Interview with the Administrator on 2/21/19 at 11:15 AM in the resident's room confirmed .there should not be a hole in the resident's foot board .",2020-09-01
1175,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2019-02-21,641,D,0,1,GXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility investigation, and interview, the facility failed to accurately assess 1 resident (#54) of 21 residents reviewed. The findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation dated 2/4/19 revealed Resident #54 slid out of the bed onto the floor. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #54 had no falls since admission/entry or reentry or prior assessment. Interview with the Licensed Practical Nurse #1, responsible for the MDS, on 2/20/19 at 1:20 PM in her office confirmed Resident #54, .did have a fall on 2/4/19 and it should have been captured on the 30 day MDS .",2020-09-01
1176,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2019-02-21,695,D,0,1,GXQE11,"**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 provide necessary respiratory care for 2 residents (#48 and #65) of 32 residents receiving respiratory services. The findings include: Facility policy review, Respiratory System Management revised 5/2017 revealed .Attach a clean, dated plastic bag to the oxygen source to be used to store the equipment when not in use. Plastic bags are replaced weekly and as needed . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #48's physician order [REDACTED].administer oxygen 2.0 LPM (liters per minute) per NC (nasal cannula) as needed for shortness of breath . Medical record review of Resident #48 physician order [REDACTED].change & date oxygen tubing & humidifier bottle weekly . Observation on 2/19/19 at 8:45 AM and at 9:00 AM in Resident #48's room revealed the oxygen tubing was not dated or bagged, and was placed over the oxygen concentrator and lying on the floor. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician orders [REDACTED].Oxygen at 2 LPM per nasal cannula as needed for SOB (Shortness of Breath) related to Adult Failure to Thrive, Generalized Anxiety Disorder .Change and date oxygen tubing and humidifier bottle weekly on night shift every Sunday related to Adult Failure to Thrive, Generalized Anxiety Disorder . Medical record review of electronic Medication Administration Record [REDACTED]. Further review revealed oxygen tubing was documented as being changed weekly with last change dated 2/17/19. Observation on 2/19/19 at 9:25 AM and 3:40 PM in Resident #65's room revealed oxygen tubing hanging on an oxygen cylinder (E-cylinder) in a stand in his room unlabeled and unbagged. Interview with Resident #65's sister on 2/19/19 at 4:00 PM in the dining room revealed .he started oxygen in (MONTH) for a panic attack and abnormal breathing .he became dependent on oxygen with repeated panic attacks during the last several months .but they finally weaned him off at the end of (MONTH) . Observation on 2/20/19 at 7:45 AM in Resident #65's room revealed oxygen tubing hanging on the e-cylinder in the stand in his room unlabeled and unbagged. Interview with the Director of Nursing (DON) on 2/21/19 at 7:58 AM and 10:15 AM in her office confirmed .I expect to find oxygen tubing bagged and dated in all patient rooms .",2020-09-01
1177,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2019-02-21,758,D,0,1,GXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to provide monitoring related to performing an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner for 1 resident (#13) of 4 residents reviewed receiving [MEDICAL CONDITION] medications. The findings include: Review of the facility policy, Behavior Management, revised (MONTH) (YEAR) revealed .Monitoring for any adverse side effects of medications, which includes completion of Abnormal Involuntary Movement Scale (AIMS) as per recognized standards of practice . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated (MONTH) 2019 with an origination date of 10/22/18 revealed, .[MEDICATION NAME] (antipsychotic medication) 0.5 milligrams (mg) one time a day at bedtime . Medical record review revealed Resident #13's AIMS assessment was dated 3/21/18. Interview with the Director of Nursing on 2/20/19 at 3:25 PM in the conference room revealed the AIMS assessments were to be done every 6 months. Further interview confirmed there was no AIMS assessment done for Resident #13 after (MONTH) (YEAR). Interview with the Pharmacy Consultant on 2/20/19 at 3:40 PM at A/B Hall Nurses Station confirmed the AIMS assessments were to be done every 6 months.",2020-09-01
1179,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2018-03-07,641,D,1,1,K5H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to accurately assess the swallowing impairment for 1 of 31 residents reviewed (Resident #121). Findings include: Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Pureed diet had been ordered and Speech Therapy was ordered to evaluate and treat. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #121 had no swallowing impairment and was on a mechanically altered texture diet. Interview with the Speech Therapist on 3/7/18 at 12:08 PM in the rehabilitation department confirmed Resident #121 was evaluated on 12/15/17. Further interview confirmed Resident #121 had been evaluated to have swallowing impairment and required a pureed diet for safe eating. Further interview revealed the therapy was discontinued on 12/26/17 and the resident's ability to swallow had not changed or improved from the time of the evaluation. Interview with the Director of Nursing on 3/7/18 at 3:07 PM in the conference room confirmed the resident had swallowing difficulties. Further interview confirmed the MDS dated [DATE] failed to identify the swallowing impairment.",2020-09-01
1180,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2018-03-07,661,D,0,1,K5H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to complete a discharge recapitulation for 1 of 3 discharged residents reviewed (Resident #69). Findings include: Review of the facility policy Discharge Summary revised 8/2017 revealed .When the facility anticipates discharge a resident must have a discharge summary that included: 1) A recapitulation of the resident's stay that includes but not limited to a. [DIAGNOSES REDACTED]. Pertinent lab, radiology, and consultation results . Medical record review revealed Resident #69 was most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to another facility on 12/8/17. Medical record review of the Social Service progress notes revealed on 12/7/17 .Spoke with spouse and step-daughter today .Hospice social worker has been working with family on transferring resident to a facility that has a VA (Veterans Administration) contract . Medical record review revealed on 12/8/17 a physician order to transfer to (another facility). Medical record review revealed no discharge recapitulation of the services provided while in the facility. Interview with the Director of Nursing and Registered Nurse #1 on 3/7/18 at 4:12 PM, in the hallway outside the medical record office, confirmed the facility failed to have a discharge recapitulation of the facility services provided during the facility admission.",2020-09-01
1182,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2017-05-02,225,D,1,0,E04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to report and fully investigate an allegation of misappropriation for 1 Resident (#7) of 8 residents reviewed. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation dated 2/14/17 revealed in late 1/2017 CNA #1 beckoned Physical Therapist (PT) #1 into a residents room were she witnessed CNA #1 remove (3) $100 bills from a white envelope inside the wallet of Resident #7 and then placed the envelope back in the wallet and gave it to the PT and told her to give the wallet back to Resident #7. Review of the facility investigation revealed the facility failed to report and fully investigate the allegation of Misappropriation to the State Agency as required. Telephone interview with the Human Resource (HR) coordinator on 4/13/17 at 7:56 AM confirmed the facility failed to report and fully investigate the allegation of Misappropriation to the State Agency as required.",2020-09-01
1183,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2017-05-02,514,D,1,0,E04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain complete and accurate medical records for 2 residents (#2, #4) of 8 residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].IV (intravenous) NS (normal saline) at 125ml/hr (milliliters per hour times) 2 liters, hypovolemia. Medical record review of a physician's orders [REDACTED]. Medical record review revealed the facility did not have a policy for hypodermoclysis in effect at the time the procedure was administered on 12/30/16 to Resident #2. Interview with the Director of Nursing (DON) on 4/10/17 at 2:30 PM in the conference room confirmed she failed to write the verbal order from the physician for the procedure hypodermoclysis and the facility did not have a policy in effect for the procedure hypodermoclysis on 12/30/16. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Re-Admit Admission Assessment for 1/13/17 revealed the admission assessment was not done. Interview with the DON on 4/12/17 at 5:00 PM in her office confirmed the nurse failed to complete the Re-Admit Admission Assessment on 1/13/17.",2020-09-01