cms_TN
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| Link | rowid | facility_name | facility_id | address | city ▼ | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2381 | 2381 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 550 | D | 0 | 1 | YE7V11 | **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 a resident's dignity while providing personal care for 1 of 22 (Resident #74) sampled residents. The findings included: The facility's Quality of Life -Dignity policy documented, .Bodily Privacy During Care and Treatment .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the room, removed the resident's brief, turned and repositioned the resident. CNA #1 left Resident #74 fully exposed, with no cover. CNA #1 did not request permission from the resident to proceed with personal care. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to leave a resident fully exposed during personal care. The DON stated, No. | 2020-09-01 |
| 2382 | 2382 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 690 | D | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 1 of 1 (Resident #59) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Cath (catheter) care (with)soap et (and) H2O (water) q (every) shift . Observations in Resident #59's room on 1/28/18 at 4:40 PM, revealed Certified Nursing Assistant (CNA) #3 performed catheter care for Resident #59 using plain water. CNA #3 then retrieved a urinal containing a small amount of yellow liquid and emptied the catheter drainage bag into the urinal. CNA #3 tapped the spigot of the urinary drainage bag on the inside of the urinal during drainage. Interview with the Director of Nursing (DON) on 2/1/18 at 9:10 AM, in the conference room, the DON was asked what she expected staff to use for catheter care. The DON stated, Soap and water. The DON confirmed plain water was not acceptable. | 2020-09-01 |
| 2383 | 2383 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 693 | D | 0 | 1 | YE7V11 | Based on Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, observation and interview, the facility failed to ensure management of a tube feeding was preformed by qualified personnel for 1 of 1 (Resident #74) residents reviewed with a feeding tube. The findings included: Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition page 110, documented, Nursing Intervention for People Receiving Enteral Nutrition. In caring for people with tube feedings, it is the nurse's responsibility to .administer the correct amount and type of feeding at the correct rate . Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the resident's room to turn and reposition the resident. CNA #1 immediately went to the feeding pump and put it on hold. When CNA #1 completed resident care, she reumed the feeding pump. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to put a feeding pump on hold and then resume the feeding. The DON stated, No | 2020-09-01 |
| 2384 | 2384 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 812 | F | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by improper storage of food in a cooler, expired food products, and a dirty deep fat fryer. The facility had a census of 79 with 77 of those residents receiving a meal tray from the kitchen. The findings included: Observations in the kitchen on [DATE] beginning at 8:00 AM, revealed the following: (a) 1 large package of bologna with an opening in the side of the package. Interview with the Certified Dietary Manager (CDM) on [DATE] at 8:15 AM, in the kitchen, the Dietary Manager confirmed the integrity of the package of bologna was broken. Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: (a) 2 cartons of fat free milk dated [DATE] in the milk cooler. (b) 1 carton of fat free milk dated [DATE] in the milk cooler. (c) 2 bottles of protein beverages dated [DATE] in the milk cooler. Interview with the CDM on [DATE] at 11:13 AM, in the kitchen, the CDM confirmed the milk and protein beverage were out of date and stated, .I know they are not supposed to be in there. (d) The deep fat fryer had black grease and food particles on top of the grease. Interview with the CDM on [DATE] at 11:16 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, It is due to be changed . (e) 1 container of vanilla pudding with an use by date of [DATE] in the reach-in cooler. Interview with the CDM on [DATE] at 11:20 AM, in the kitchen, the CDM stated,That should have gone out. The CDM removed it from the cooler. Observations in the kitchen on [DATE] at 11:17 AM, revealed the following : (a) The deep fat fryer had black grease with food particles on top of the grease. Interview with the CDM on [DATE] at 11:19 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, Yes, ma'am it is dirty . Interview with the CDM on [DATE] at 11:19 AM, i… | 2020-09-01 |
| 2385 | 2385 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 880 | D | 0 | 1 | YE7V11 | Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN #1) nurses followed practices to prevent the potential spread of infection during medication administration. The findings included: The facility's Equipment Cleaning, Disinfecting and Maintenance policy documented, .The following equipment is cleaned/disinfected after each resident use and when visibly soiled (the list includes examples of multi-use items .Stethoscopes .after use . Observations in Resident #74's room on 1/31/18 at 1:14 PM, revealed LPN #1 went to the medication cart, retrieved a stethoscope, placed the stethoscope around her neck and returned to the bedside. LPN #1 placed the stethoscope on the Resident #74's abdomen, administered medication, and laid the stethoscope on the unsanitized overbed table. Then LPN #1 left the room, carried the stethoscope and laid it on the top of the unsanitized medication cart. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 2/1/18 at 1:37 PM, in the conference room, the DON was asked should a stethoscope be cleaned before or after administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Yes. | 2020-09-01 |
| 2386 | 2386 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 600 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of [NAME] F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to ful… | 2020-09-01 |
| 2387 | 2387 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 657 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of [NAME] A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .individualized 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 .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objecti… | 2020-09-01 |
| 2388 | 2388 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 689 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wand… | 2020-09-01 |
| 2389 | 2389 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 835 | J | 1 | 0 | 98W311 | > Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .g… | 2020-09-01 |
| 2390 | 2390 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 865 | J | 1 | 0 | 98W311 | > Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the… | 2020-09-01 |
| 2391 | 2391 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-08-30 | 609 | D | 1 | 0 | BV6Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .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 and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .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 secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed… | 2020-09-01 |
| 2392 | 2392 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 550 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 23 (Certified Nursing Assistant (CNA) #1, #4, #6, #7, and #9) facility staff members referred to clothing protectors as bibs, did not use courtesy titles to address residents, used a personal cell phone while assisting a resident with a meal, stood over a resident to assist with a meal, and failed to knock before entering a resident's room. The findings included: 1. The facility's Assisting with Meals policy documented, .Residents shall receive assistance with meals in a manner that meets the individual needs .not standing over residents while assisting them with meals .avoiding the use of labels .bibs . The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .shall be treated with dignity and respect at all times .staff shall knock and request permission before entering residents' room .Staff shall speak respectfully to residents at all times .addressing the resident by his or her name of choice and not 'labeling' .demeaning practices and standards of care that compromise dignity are prohibited .promote dignity . 2. Observations in the 400 Hall Dining Room on 10/14/19 at 12:10 PM, revealed CNA #7 stated to Resident #57, .the bib is cold, isn't it . Observations in the 400 Hall Dining Room on 10/14/19 at 12:17 PM, revealed CNA #6 stated to Resident #57, .that's your food, baby . Observations in Resident #63's room on 10/15/19 at 5:15 PM, revealed CNA #4 looked at her cell phone while she assisted Resident #63 with her meal. Observations in the 200 Hall on 10/15/19 at 5:40 PM, revealed CNA #1 entered Resident #16's room to deliver his meal tray without knocking. Observations in the 200 Hall on 10/15/19 at 5:44 PM, revealed CNA #1 entered Resident #64's room to deliver his meal tray without knocking. CNA #1 then left the room, returned at 5:50 PM, and entered again without knocking. Observations in Resident #243's room on 10/16/19 at 12:40 PM, revealed CNA #9 s… | 2020-09-01 |
| 2393 | 2393 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 565 | E | 0 | 1 | PSHT11 | Based on observation and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: Observations in the Sunroom on 10/15/19 at 10:00 AM, revealed the Resident Council Meeting location was not completely private. A bi-fold screen was used to block the entrance from hall 500 to the Sunroom but was accessible to anyone on the 500 Hall. During the meeting there were three interruptions: a. A resident on the 500 Hall folded the bi-fold screen, wheeled through the Sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. b. A Certified Nursing Assistant (CNA) from the 500 Hall folded the bi-fold screen, wheeled a resident through the sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. c. The Activity Director entered the room during the meeting and assisted one of the residents to leave the room. Interview with Activity Assistant #2 on 10/17/19 at 9:36 AM in the 400 Hall, Activity Assistant #2 stated, The Resident Council Meeting should never be interrupted. | 2020-09-01 |
| 2394 | 2394 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 577 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure the survey results were readily accessible for all residents residing in the facility. The facility had a census of 98 residents. The findings include: 1. The facility's undated Resident Rights policy documented, .results of the most recent survey of the Center conducted by Federal or State surveyors and any plan of correction in effect to the Center. The Center must make the results available for examination in a place readily accessible to residents . 2. Observations in the Lobby on 10/14/19 at 9:05 AM and 10/15/19 at 11:42 AM, revealed a white binder labeled .Survey Results The results from surveys on 6/10/19, 7/2/19, and 8/30/19 were not available for the residents to review. Interview with the Administrator on 10/16/19 at 4:46 PM, in the Lobby, the Administrator was asked if the survey results were in the survey book from the surveys conducted (June, July, and Sept of 2019). The Administrator stated, .no they are not in there . The Administrator was asked if the survey results should be in the book available for residents to review. The Administrator stated, .yes . | 2020-09-01 |
| 2395 | 2395 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 658 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 1 of 2 nurses (Licensed Practical Nurse (LPN) # 4) failed to follow facility policy for administration of medications through a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for nutrition and medication) when medications were pushed through the enteral tube and not allowed to flow per gravity. The findings included: The facilities Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .Administer medication by gravity flow . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Thera liquid give 10 ml (milliliter) .peg .once a day .[MEDICATION NAME] formula capsule .once daily . The physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet per peg . The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram)/5 ml susp (suspension) give 7 ml .PEG 2 TIMES DAILY @ (at) 6 AM & (and) 6 pm . Observations in Resident #35's room on 10/15/19 at 5:09 PM, revealed LPN #4 poured 60 ml of water into Resident #35's PEG and pushed the water through the tube with the plunger. LPN #4 then administered the medications with water and pushed each medication through the tube with the plunger. LPN #4 poured 60 mL of water into the PEG tube and pushed the water through the tube with the plunger. LPN #4 did not allow the medications to flow by gravity, in accordance with the facility's policy. Interview with the Director of Nursing (DON) on 10/17/19 at 7:15 PM, in the Conference Room, the DON was asked should medications be pushed through a PEG tube. The DON stated, .no .should be by gravity . | 2020-09-01 |
| 2396 | 2396 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 684 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for wound care treatments for 1 of 4 (Resident #70) sampled residents reviewed for wound care. The findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #70 required staff assistance for all activities of daily living, and had Moisture Associated Skin Damage (MASD). The care plan dated 2/25/19 documented, .at risk for skin breakdown r/t (related to) decreased mobility, incontinence .Intervention .Treatments as directed . The Physician's Orders dated 10/7/19 documented, .Start Date .10/03/19 .RLE (Right Lower Extremity) AND LLE (Left Lower Extremity) EXCORIATION .CLEAN C (with) NS (Normal Saline), APPLY SSD (Silver [MEDICATION NAME])/[MEDICATION NAME]/[MEDICATION NAME]/ZINC TRIPLE CREAM EQUAL MIXTURE TO AFFECTED AREAS DAILY ET (and) PRN (as needed) X (times) 14 DAYS, THEN RE-EVALUATE . The Wound Assessment Report dated 10/15/19 documented, .MASD .apt (appointment) (with) .wound clinic on 10/15/19 .N.O. (new order) Cont (Continue) to apply SSD/[MEDICATION NAME]/[MEDICATION NAME]/zinc combined triple cream equal parts to affected areas daily . Observations in Resident #70's room on 10/16/19 at 10:55 AM, revealed Licensed Practical Nurse (LPN) #1 performed wound care to raised reddened areas to Resident #70's bilateral posterior upper thighs. LPN #1 wiped the wound with Aloe disposable wipes, and then applied SSD 1 percent (%) cream to the area. Interview with LPN #1 on 10/17/19 at 6:51 PM, in the 500 Hall, LPN #1 confirmed she applied SSD 1% cream to Resident #70's MASD wounds. LPN #1 was asked if the treatment was administered as ordered. LPN #1 stated, .This is what they sent from (Named Pharmacy) . Interview with the Director of Nursing (DON) on 10/17/19 at 6:54 PM, in the 500 Hall… | 2020-09-01 |
| 2397 | 2397 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 725 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility staffing schedules 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. The facility had a census of 98 residents. The findings include: 1. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #31 on 10/14/19 at 3:07 PM, in Resident #31's room, Resident #31 was asked about staffing at the facility. Resident #31 stated, Not at night time especially. They say it's just 1 or 2 (staff members) at night. Resident #31 was asked if he had to wait a long time for someone to help him if he called for help. Resident #31 stated, .takes an hour or 2 and sometimes 3 or 4, takes a long time . Even sometimes in the daytime they don't come as quick as they should. 2. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #29 on 10/14/19 at 3:58 PM, in Resident #29's room, Resident #29 was asked about staffing at the facility. Resident #29 stated, Sometimes at night it's pretty bad, especially at bedtime .have to wait at least 30 minutes before they can go to bed .sometimes at night it's way more than 30 minutes . 3. Review of the admission MDS dated [DATE] revealed Resident #143 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #143 on 10/15/19 at 8:09 AM, in Resident #143's room, Resident #143 was asked about staffing at the facility. Resident #143 stated, A lot of times at night we only have 1 aide for 30-something patients .they (call lights) might go off 30 minutes to an hour before they're answered. 4. During the Resident Council Group meeting, which consisted of 12 alert and… | 2020-09-01 |
| 2398 | 2398 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 757 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the PHYSICIANS' DESK REFERENCE 69th EDITION, medical record review, observation, and interview, the facility failed to ensure medications administered were appropriately monitored for adverse effects for 1 of 6 (Resident #16) sampled residents reviewed for unnecessary medications. The findings include: 1. The PHYSICIANS' DESK REFERENCE 69th EDITION (YEAR) documented, .[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication) .INDICATIONS AND USAGE .[MEDICAL CONDITION] .Pituitary TSH ([MEDICAL CONDITION] Stimulating Hormone) Suppression .PRECAUTIONS .has a narrow therapeutic index .Regardless of the indication for use, careful dosage titration is necessary to avoid the consequence of over- or under-treatment .These consequences include .effects on .cardiovascular function, bone metabolism .cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism .The adequacy of therapy is determined by periodic assessment of appropriate labortory tests .frequency of TSH monitoring during [MEDICATION NAME] dose titration .is generally recommended at 6-8 week intervals until normalization .When the optimum replacement dose has been attained .It is recommended .a serum TSH measurement be performed at least annually . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Unspecified Sequelae of Other [MEDICAL CONDITION] Disease. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision for all activities of daily living. A hospital discharge summary report dated 3/21/18 documented, .TSH ([MEDICAL CONDITION] Stimulating Hormone) .2/28/2018 .Result .6.44 .H (High) .Reference Range .0.45 - 5.0 .ulU/ml (micro-international units per milliliter) . The physician's orders [REDACTED].Start Date .6/30/18 .[MEDICATION NAME] 0.025 MG (milligrams) TABLET by mouth @ … | 2020-09-01 |
| 2399 | 2399 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 759 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the JoVE Science Education Database Nursing Skills. Preparing and Administering Intramuscular Injections, medical record review, observation, and interview, the facility failed to ensure 2 of 8 (Licensed Practical Nurse (LPN) #2 and #3) 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 included: 1. The JoVE Science Education Database. Nursing Skills Preparing and Administering Intramuscular Injections documented, .The deltoid site (upper arm) .immunizations .maximum volume should never exceed 2 mL (milliliters) . The facilty's Administering Medications policy revised (MONTH) 2019 documented, .Medications are administered in a safe and timely manner, and as prescribed .The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 120 mg (milligram) IM (intramuscular) q (every) 12 hrs (hours) x (for) 14 days . Observations in Resident #18's room on 10/16/19 at 9:15 AM, revealed LPN #2 injected 3 ml of [MEDICATION NAME] into Resident #18's left upper arm (deltoid site). Interview with the Director of Nursing (DON) on 10/17/19 at 8:23 PM, in the Conference Room, the DON was asked is it acceptable to give 3 ml of medication Intramuscular (IM) in the upper arm. The DON stated, .no . Failure of LPN #2 to administer an IM injection of [MEDICATION NAME] of less than 2 ml into the deltoid site resulted in medication error #1. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .1… | 2020-09-01 |
| 2400 | 2400 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 760 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information, policy review, medical record review, and interview, the facility failed to ensure medications were administered free from significant medication errors for 1 of 24 (Resident #70) sampled residents. The findings include: 1. The (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information documented, .Take [MEDICATION NAME] once a day . 2. The facility's Medication and Treatment Orders policy with a revision date of 7/2016, documented, .Orders for medications must include .Dosage and frequency of administration .Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders . 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 2/25/19 documented, .insulin dependent diabetic .at risk for hypo/[MEDICAL CONDITION] and complications of the disease .Intervention .Medications .as directed per MD (Medical Doctor) .orders . The Physician admission orders [REDACTED].[MEDICATION NAME]-5mg (milligrams)-take 1 tab (tablet) po (by mouth) before meals . The Telephone physician's orders [REDACTED].Order Clarification .[MEDICATION NAME] 5mg po (by mouth) QD (every day) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 Monthly Consultant Pharmacist Report documented, .Please note the following medication(s) are dosed above the usual geriatric dosage .[MEDICATION NAME] 5mg tid (three times daily) .Recommendation .[MEDICATION NAME] 5mg daily . Telephone interview with the Pharmacist on 10/17/19 at 8:52 AM, the Pharmacist was asked if there had been a problem with Resident #70's diabetic medication, [MEDICATION NAME]. The Pharmacist stated, Yes .There's no way they are supposed to be given three times a day .it w… | 2020-09-01 |
| 2401 | 2401 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 761 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 9 (500 Lower Hall Medication Cart) medication storage areas was unlocked and unattended. The findings included: The facility's Storage of Medications policy revised (MONTH) 2019 documented .drugs and biologicals .are stored in locked compartments .unlocked medication carts are not left unattended . Observations in the 500 Hall on 10/15/19 at 8:16 PM, the 500 Lower Hall Medication Cart was left unlocked and unattended. Interview with the Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked if medication carts are to be left unlocked. The DON stated, .no . | 2020-09-01 |
| 2402 | 2402 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 812 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by a dirty hand-washing sink in the Kitchen, dishwashing racks stored on the floor in the Kitchen, opened, unlabeled and undated foods stored in the Kitchen and in 1 of 3 (,[DATE] Hall Nourishment Room) nourishment rooms, wet towel on the floor in the Kitchen, a dirty steam table in the Kitchen, raw chicken and frozen foods left sitting at room temperature in the Kitchen, and foods on the floor in the Kitchen. The facility had a census of 98 residents, with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's FOOD STORAGE policy with a revision date of [DATE], documented, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label and date .Chicken should be stored on ice to maintain an optimal temperature .Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture .milk .should be stored .in refrigeration at 41 (degrees) F (Fahrenheit) or less .All foods should be stored .off the floor .Internal thermometers are to be in the warmest area of the refrigerator or freezer .Record temperatures from the internal thermometers .Employee food and resident food should not be stored together . 2. Observations in the Kitchen on [DATE] beginning at 8:45 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. Two dish racks on the floor in the dishware washer area. The Dietary Manager (DM) confirmed they were on the floor, and picked them up. c. A milk cooler filled with milk and no thermometer inside. The DM confirmed there were no thermometers in the milk cooler. The DM stated, M… | 2020-09-01 |
| 2403 | 2403 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 842 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Resident Assessment Instrument (RAI) Manual, policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to pressure ulcers for 1 of 4 (Resident #31) sampled residents reviewed for pressure ulcers and medication administration related to insulin and intravenous (IV) antibiotics for 2 of 6 (Resident #59 and #61) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the RAI Manual, (YEAR) Minimum Data Set (MDS) 3.0 Updates, revealed that when a resident who is admitted to the nursing home without a pressure ulcer develops a pressure ulcer in the nursing home, is admitted to the hospital for acute condition changes and then readmitted to the nursing home with the same pressure ulcer, that pressure ulcer is not considered present on admission but is a facility acquired pressure ulcer. Medical record review revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly Wound Assessment Report dated 3/27/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date Wound Identified .8/29/2017 .Present upon admission .No .Stage 4 . A weekly Wound Assessment Report dated 4/2/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date wound identified .4/2/19 .Present upon admission .Yes .Assessment Occasion .Re-assessment .Resident out of the facility From Date .3/28/2019 .Thru Date .4/2/2019 . All weekly Wound Assessment Reports from 4/2/19 through 10/15/19 documented, .Date wound identified .4/2/2019 .Present upon admission .Yes . Observations in Resident #31's room on 10/16/19 at 10:08 AM, revealed wound care was performed on Resident #31's Stage 4 coccyx pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 10/16/19 at 3:10 PM, in the 400 Hall Dining Area, LPN #1 was asked if Resident #31 had a stage 4 coccyx pressure ulcer when he went out to the … | 2020-09-01 |
| 2404 | 2404 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 880 | D | 0 | 1 | PSHT11 | **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 when isolation precautions were not followed for 1 of 2 (Resident #49) sampled residents reviewed and facility staff failed to protect resident's personal clothing from environmental contamination. The findings include: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) (YEAR) revealed .when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (The Centers for Disease Control) (CDC) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Pt (patient) to be in contact isolation r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in wound . Observations in the 500 Hall on 10/14/19 at 8:30 AM, revealed no isolation signs on Resident #49's door. Resident #49 had a roommate who was not in isolation. Observations in the 500 Hall on 10/14/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #7 donned gloves to enter Resident #49's room. LPN #7 confirmed that she wore gloves only because his wounds were contained and he was not contagious. Observations on 10/15/19 in the 500 hall revealed the following: a. Certified Nursing Assistant (CNA) #3 entered Resident #49's room at 8:00 AM to deliver the breakfast tray. CNA #3 did not wear gloves or any Personal Protective Equipment (PPE) when she entered the room. b. CNA #4 entered Resident #49's room at 5:… | 2020-09-01 |
| 2405 | 2405 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 584 | D | 0 | 1 | 38WC11 | Based on policy review, observation, and interview the facility failed to maintain a sanitary environment in 1 of 50 (Resident #21, 30, 48, and 66's shared bathroom) resident bathrooms. The findings include: 1. The facility's Cleaning and Disinfecting residents' Rooms policy with a revision date of 8/13 documented, .Housekeeping surfaces .will be cleaned on a regular basis .and when these surfaces are visibly soiled . 2. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 11:12 AM revealed bowel movement in the toilet, a brown substance smeared on the toilet seat, and crumpled used paper towels lying on top of the toilet tissue dispenser beside the toilet. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 2:39 PM and 4:35 PM revealed a brown substance smeared on the toilet seat and on top of the toilet tissue holder beside the toilet. Interview with Certified Nursing Assistant (CNA) #1 on 12/10/18 at 4:38 PM in Resident #21, 30, 48, and 66's shared bathroom, CNA #1 was asked who cleaned the bathrooms. CNA confirmed it was housekeeping staff. CNA #1 was asked how often they are cleaned. CNA #1 stated, They are here from 6 in the morning until .maybe 2. I don't see them after I come back from lunch. CNA #1 was asked if the smeared brown substance on the toilet seat and on the toilet tissue dispenser was acceptable. CNA #1 stated, No, not at all. CNA #1 was asked if the residents use that bathroom. CNA #1 stated, Yes, (Resident #30) does. Interview with the Director of Nursing (DON) on 12/12/18 at 2:27 PM in the conference room , the DON was asked how often he expected staff to make rounds in resident rooms and bathrooms. The DON stated, At least every 2 hours and PRN (as needed) . The DON was asked if it was acceptable for a resident bathroom to have unflushed bowel movement in the toilet, a brown substance smeared on the toilet seat and on the toilet paper dispenser in a resident's bathroom. The DON stated, No ma'am. | 2020-09-01 |
| 2406 | 2406 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 604 | D | 0 | 1 | 38WC11 | **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 from physical restraints for 1 of 1 (Residents #77) resident reviewed for restraints. The findings include: The Physical Restraint Application policy dated (MONTH) 2010 documented, .Physical restraints are defined by Centers for Medicare and Medicaid Services (CMS) 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 .The resident must be physically and cognitively able to self-release devices such as .seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment and no use of physical restraints. The Care Plan dated 11/8/18 documented, .May use seat belt on wheelchair for safety. Check every 30 min (minutes) and release every 2 hours . The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM, and on12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in her wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) in the conference room on 12/10/18 at 1:13 PM, the DON was asked about the seat belt. The DON stated, .She has had it for at least 3 years . Interview with Certified Nursing Assistant (CNA) #2 on 12/12/18 at 8:47 AM on the 400… | 2020-09-01 |
| 2407 | 2407 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 623 | D | 0 | 1 | 38WC11 | **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 an emergency transfer for 1 of 4 (Resident #65) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].send to ER (emergency room ) . Review of the facility's Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #65 was not on the list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #65 was transferred to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 12/12/18 at 9:38 AM in the conference room, the DON confirmed Resident #65 was not on the (MONTH) Emergency Transfer form. | 2020-09-01 |
| 2408 | 2408 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 641 | D | 0 | 1 | 38WC11 | **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 physical restraints for 1 of 18 (Resident #77) sampled residents reviewed. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADLs), and no use of physical restraints. The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM and on 12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) on 12/12/18 2:47 PM in the conference room, the DON was asked whether the seat belt and Pommel cushion should be coded as restraints on the MDS assessments. The DON stated, It is not coded as a restraint, because it is not a restraint. The facility was unable to provide documentation that a restraint assessment was performed to determine if the seat belt and pommel cushion were restraints. | 2020-09-01 |
| 2409 | 2409 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 656 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to follow care plan interventions related to pain assessments for 2 of 18 (Resident #40, and #64) sampled residents. The findings include: 1. The facility's Using the Care Plan policy documented, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .6. Documentation must be consistent with the resident's care plan . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The Care Plan dated 11/3/18 documented, .Evaluate pain at least Q (every) shift and PRN (as needed). Administer pain medication as needed and evaluate effectiveness. Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at the 100 hall nurse station, LPN #1 was asked if the Pain Assessments were completed for Resident #40. LPN #1 stated, We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON confirmed the pain assessments were not documented on the Medication Administration Record. The DON was asked if the pain assessments were documented for Resident #40 and if the care plan was being followed for Resident #40. The DON stated, No. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (restless leg syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on MAR (Medication Administration Record) . Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she … | 2020-09-01 |
| 2410 | 2410 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 697 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure pain assessments were completed according to the facility policy for 2 of 7 (Resident #40 and Resident#64) sampled residents reviewed for pain. The findings include: 1. The facility's Pain Assessment and Management policy with a revised date of (MONTH) (YEAR) documented, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Document the resident's reported level of pain .Upon completion of the pain assessment, the person shall record the information obtained from the assessment in the resident's medical record . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #40 was severely cognitively impaired, required extensive to total staff assistance for activities of daily living, and received scheduled pain medication or was offered as needed (PRN) pain medications. The Care Plan dated 11/3/18 documented, .at risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] and End Stage disease process .Resident will be kept comfortable while on hospice .Evaluate pain at least Q (every) shift and PRN. Administer pain medication as needed and evaluate effectiveness. The physician's orders [REDACTED].[MEDICATION NAME] HCL 50 MG (milligrams) TABLET GIVE 1/2 TABLET 25 MG BY MOUTH AS NEEDED EVERY 8 HOURS FOR PAIN .10/29/18 .[MEDICATION NAME] 300 MG CAPSULE BY MOUTH THREE TIMES DAILY . Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at 100 hall's nurses station, LPN #1 was asked if the Pai… | 2020-09-01 |
| 4152 | 4152 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 279 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a plan of care that identified the resident's dental status for 1 of 2 (Resident #22) sampled residents of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted 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 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken .the care planning decision is marked yes .there should have been a care plan for dental. The facility was unable to provide a care plan for Resident #22's dental status. | 2019-11-01 |
| 4153 | 4153 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 332 | D | 0 | 1 | HQE411 | **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 5 (Licensed Practical Nurse (LPN) #1) staff nurses administered medications with a medication error rate of less than 5 Percent (%). A total of 5 medication errors were made out of 25 opportunities, resulting in a medication error rate of 20%. The findings included: The facility's Crushing Medications policy documented, .Crushed medications should be administered with .soft foods to ensure that the resident receives the entire dose ordered . Medical record reviewed revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].MAY CRUSH ALL CRUSHABLE MEDS (medications) MIXED IN PUDDING .[MEDICATION NAME] .0.75(milligrams) .STRESS B WITH ZINC TABLET GIVE 1 .[MEDICATION NAME] ([MEDICATION NAME]) 100 MG (MILLIGRAMS) CAPSULE .[MEDICATION NAME] .7.5 MG TABLET .[MEDICATION NAME] 100 MG 1 (TABLET) . Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 administered [MEDICATION NAME] 0.75 mg, Stress Formula with Zinc, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 100 mg crushed in a cup mixed with pudding. LPN#1 left pill fragments in the cup and on the spoon. Interview with the Director of Nursing (DON) on 11/16/16 at 11:35 AM, in the DON's office, the DON was asked if is it appropriate for any of the crushed medications to be left in the cup or on the spoon after medication administration. The DON stated, No. | 2019-11-01 |
| 4154 | 4154 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 371 | F | 0 | 1 | HQE411 | Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up on pans, the deep fryer, the flat grill, and the oven, and by dietary staff with exposed hair in the kitchen on 2 of 3 (11/14/16 and 11/15/16) days of the survey. The facility had a census of 89, with 86 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's POTS AND PANS - SANITIZING SOLUTION policy documented, .Pots and pans need to be free of black buildup deep scratches and dents . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up and grease on 6 sheet pans. Interview with the Dietary Manager (DM) on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon and grease build-up on sheet pans in the clean area. The DM stated No, it's not acceptable. 2. The facility's DEEP-FAT FRYER policy documented, .Turn off the heating element, drain, rinse with warm vinegar water then rinse thoroughly with clear hot water .wipe the fryer completely dry .Clean the outside of the fry kettle with grease solvent . The facility's OVEN - CONVENTIONAL, GAS policy documented, .remove spills, spillovers, and burned food deposits . The facility's GRILL - GAS policy documented, .Scrape grill to loose burned-on particles .Wash back and side guards with soap and water . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up on the deep fryer, the flat grill, and the oven. Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon build-up on kitchen equipment. The DM stated, No, it's not acceptable. 3. The facility's PERSONAL HYGIENE policy documented, .Wear .a hair restraint .Hair must be .completely covered . Observations in the kitchen on 11/14/16 and 11/15/16 revealed the following Dietary Staff (DS) with exposed hair: a. 11/14/… | 2019-11-01 |
| 4155 | 4155 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 412 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide dental services to meet the needs of 1 of 2 (Resident #22) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted 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 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Marketing Director/Interim Social Worker (MDISW) on 11/16/16 at 7:51 AM, on the 300 hallway, the MDISW was asked if she had any information about Resident #22's broken and missing dentures. The MDISW stated, I have not heard of anything . Interview with the MDISW on 11/16/16 at 8:41 AM, in the conference room, the MDISW stated, I checked, and he is not on any (dental) list .MDS did not communicate it over, so that is why he was missed . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are… | 2019-11-01 |
| 4156 | 4156 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 441 | D | 0 | 1 | HQE411 | Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) staff nurses failed to clean a stethoscope before or after use, and failed to perform proper hand hygiene during medication administration. The findings included: Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 placed the stethoscope on the resident's skin to check placement of a percutaneous endoscopic gastrostomy (PEG) tube. LPN #1 failed to clean the stethoscope before and after medication administration through Resident #5's PEG tube. Observations in Residents #77's room on 11/15/16 beginning at 10:53 AM, revealed LPN #2 used gloved hands to administer nasal spray medication to Resident #77. LPN #2 then went back to the medication cart in the hall, picked up a pen, opened the Medication Administration Record (MAR) binder, and began writing, all while still wearing the contaminated gloves. Interview with the Director of Nursing (DON) on 11/16/15 at 11:35 AM, in the DON's office, the DON was asked whether she expected staff to clean the stethoscope before and after checking PEG tube placement. The DON stated, Yes. The DON was asked whether it was appropriate to walk out of the room, touch a pen and chart while still wearing gloves that were worn during nasal spray administration. The DON stated, No. | 2019-11-01 |
| 5673 | 5673 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2015-09-30 | 250 | E | 0 | 1 | DWQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of a job description, medical record review, and interview, the facility failed to ensure the Social Service Director (SSD) participated, reviewed and updated the plans of care during quarterly interdisciplinary care plan meetings for 13 of 17 (Residents #5, 7, 34, 36, 44, 58, 85, 88, 92, 93, 108, 109 and 118) sampled residents of the 27 residents included in the stage 2 review. The findings included: 1. The facility's Social Services Role and Policies policy documented, .Social services staff will participate as members of the interdisciplinary team (IDT), which reviews and plans the care of the resident . Social services will evaluate how the resident has adapted to the facility and whether there are any current personal needs. Social services will also determine whether there are any psychosocial adjustments or behavior problem . Social services will chart at least every 3 months. This documentation will include progress toward the care plan goals for identified psychosocial problems. Care plan approaches and problems will be re-evaluated at that time to ensure that they are working, and revisions will be done as needed . Duties include the following . 6. Participate as part of the interdisciplinary team in maintaining a plan of care . 2. The facility's SSD job description documented, .Participate in resident care planning by identifying the social and emotional needs of the residents in accordance with the medical assessment . Maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15, 5/14/15 and 8/5/15, revealed no documentation that the SSD participated in the quarterly care planning process t… | 2019-01-01 |
| 7335 | 7335 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2014-08-20 | 371 | D | 0 | 1 | ECQ511 | Based on policy review, review of the kitchen cleaning schedule, observation, and interview, it was determined the facility failed to maintain kitchen sanitation as evidenced by 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, sides and back splash of the fryer and a dark brown grease inside the fryer on 2 of 3 (8/18/14 and 8/19/14) days of the survey. The findings included: 1. Review of the facility's Dietary Department Guidelines policy documented, .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner . All areas of the dietary department will be cleaned on a regular schedule . 2. Review of the facility's kitchen cleaning schedule documented: .Sweep/mop under Everything . Each Shift . Deep Fryer . Daily . BEFORE LEAVING ON SUNDAY MAKE SURE THERE IS NOTHING ON THE FLOOR . 3. Observations in the kitchen on 8/18/14 at 9:38 AM, revealed 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer. 4. Observations in the kitchen on 8/19/14 at 11:05 AM, revealed the 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer was still present during the second day of the survey. 5. During an interview in the kitchen on 8/19/14 at 11:05 AM, the Dietary Manager was asked should the area around the fryer be clean. The Dietary Manager stated, Yes. | 2018-02-01 |
| 9365 | 9365 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 278 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for hospice care, pressure sores and/or falls 2 of 35 (Residents #20 and 53) sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].D/C (discharge) from Skilled Services to Hospice on 2/24/13 Hx (history) Dx (diagnosis) Lung CA (cancer) . Review of a significant change MDS dated [DATE] documented, .Section O . Special Treatments, Procedures, and Programs . Check all of the following treatments, procedures, and programs that were performed during the last 14 days . K. Hospice care . The box for hospice care was not checked. During an interview at the skilled nurses' station on 5/21/13 at 2:30 PM, Nurse #3 was asked to find the current order for hospice care for Resident #20. Nurse #3 stated, Here it is written on 2/22/13 . During an interview in the MDS office on 5/22/13 at 8:00 AM, MDS Nurse #2 stated, .we have to do a sig (significant) change on them when they go into hospice . MDS Nurse #1 was asked if the MDS was coded for hospice. MDS Nurse #1 stated to MDS nurse #2, .no you forgot to mark it . 2. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #53's nurses' notes dated 2/20/13 documented a 4:30 PM admission note that included, .also noted to inner buttocks 1.3 cm (centimeters) X (by) 0.3 cm open area . Review of the admission MDS assessment, dated 2/27/13 documented, .M0210. Unhealed Pressure Ulcer(s) . Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher . This pressure sore question was coded with a 0, indicating No. During an interview at the 500 hallway nurse's station on 5/21/13 at 8:10 AM, Nurse #2 stated Resident #53 was admit… | 2017-01-01 |
| 9366 | 9366 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 279 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to have a care plan for vision for 1 of 35 (Resident #62) sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] and 10/26/12 documented, Section B - Hearing, Speech, Vision . B0100 impaired - see large print but not regular print . Review of care plan dated 10/19/12 did not included care for vision. Observations in Resident #62's room on 5/21/13 at 8:00 AM, revealed Resident #62 sitting on side of bed working a puzzle using a magnifying glass. During an interview in Resident' #62's room on 5/22/13 at 7:45 AM, Resident #62 stated, I picked out me some frames for some glasses last week . I can't wait till (until) they (glasses) get here . During an interview in the MDS office on 5/22/13 on 9:00 AM, MDS Nurse #1 was asked should vision be care planned. MDS Nurse #1 stated, .vision should be in the care plan and it is not there . | 2017-01-01 |
| 9367 | 9367 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 309 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure physician orders [REDACTED].#125) sampled residents included in the stage 2 review. The findings included: Review of the facility's Lab (laboratory) and Diagnostic Test Results-Clinical Protocol policy documented, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs . Medical record review for Resident #125 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the original physician's orders [REDACTED].#125 documented, .LAB ORDERS . CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) EVERY 6 MONTHS . The facility was unable to provide results of the CBC and BMP that were due in 3/13. During an interview in the conference room on 5/22/13 at 10:50 AM, the Director of Nursing (DON) was asked for the results of the CBC and BMP that was due in 3/13. The DON stated, .it's (3/13 lab work) not there . it wasn't done . | 2017-01-01 |
| 9368 | 9368 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 314 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure pressure sore treatments were done for 1 of 2 (Resident #67) sampled residents reviewed with pressure ulcer of the 35 residents included in the stage 2 review. The findings included: Review of the facility's treatment of [REDACTED]. Responsibilities of team members include . Documentation . Medical record review for Resident #67 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Telephone Orders dated 5/3/13 documented, .Apply . Zinc Vaseline 1: (to) 1:1 comp (composition) to sacral area BID (two times a day) & (and) PRN (as needed) till (until) resolved . Review of the treatment record dated 5/3/13 through 5/31/13 revealed there was no pressure sore treatment documented for 5/15/13 and 5/16/13 on the 6:00 PM to 6:00 AM shift. Review of the Minimum Data Set ((MDS) dated [DATE] documented, .Section M Skin Conditions . M0700. Most Severe Tissue Type for Any Pressure Ulcer . 2. Granulation tissue . Observations in Resident #67's room on 5/21/13 at 3:30 PM, revealed Resident #67 with a stage 2 pressure sore on the sacrum area. During an interview in 400 hall nurses' station on 5/21/13 at 2:00 PM, Nurse #1 was asked should pressure sore treatments be documented. Nurse #1 stated, Yes . it (pressure sore treatments) should be documented on the treatment record . During an interview in 400 hall nurses' station on 5/21/13 at 3:00 PM, Nurse #2 was asked should pressure sore treatments be documented. Nurse #2 stated, .when treatments are done they should be documented on the treatment record . Nurse #2 was asked to verify the missing documentation for the pressure sore treatment on the treatment record for 5/15/13 and 5/16/13. Nurse #2 stated, .if (treatments were) done, it was not documented . | 2017-01-01 |
| 10878 | 10878 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 309 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to administer intravenous (IV) medications according to physician's orders [REDACTED].#6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligrams) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. A telephone order dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Review of the department notes revealed the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . b. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . c. 3/23/13 at 2:40 PM - Asked by Hall 3 nurse to attempt IV access d/t (due to) resident has orders for Meropenem 500mg IV every 12 hours until 3/25/13. Assessed resident for peripheral IV access. BUE (bilateral upper extremities) noted to be swollen and large. Multiple area of bruising noted and mulitpe (multiple) old IV sites noted. Did not attempt peripheral IV access. There was no documentation on 3/24/13 of attempts to start the IV to administer Meropenem 500 mg IV and no documentation of attempts to notify the physician of resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the ph… | 2016-04-01 |
| 10879 | 10879 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 514 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to maintain complete an accurate medical records for 1 of 6 (Resident #6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligram) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. Review of the department notes documented the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . Review of the Telephone Orders dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Further review of the department notes documented the following: a. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . b. 3/23/13 at 2:40 PM - old IV sites noted. Did not attempt peripheral IV access . There was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem does not come in an IM administration route. The DON stated, They (nurses) called the on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . The DON also confi… | 2016-04-01 |
| 12070 | 12070 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 279 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to develop an interim care plan in the first 24 hours of admission for 4 of 20 (Residents #4, 8, 11 and 12) sampled residents. The findings included: 1. Review of the facility's Care Plans----Preliminary policy documented, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission. 2. Medical record review for Resident #4 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. The first documented care plan for Resident #4 was dated 12/28/11. 3. Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 4. Medical record review for Resident #11 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide a dated interim care plan for the readmission date of [DATE]. 5. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 6. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when should a care plan be initiated. The DON stated, .within the first 24 hours of admission. | 2015-10-01 |
| 12071 | 12071 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 280 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the current status of a resident with pressure ulcers for 1 of 20 (Resident #8) sampled residents. The findings included: Review of the facility's care plan policy documented, .plan of care. shall be developed. To assure that the resident's immediate care needs are met. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 7/18/11 had no documented interventions for the [DIAGNOSES REDACTED]. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when the care plan should be initiated. The DON stated, .within the first 24 hours. | 2015-10-01 |
| 12072 | 12072 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 282 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow the care plan for turning, repositioning and skin care for 1 of 17 (Resident #8) sampled residents. The findings included: Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/29/11 documented, .Prone to skin breakdown. turn every 2 hours while in bed. Resident #8's medical record contained documentation of a hospitalized from [DATE] through 7/18/11 with a [DIAGNOSES REDACTED]. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the Director of Nursing (DON) was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours. | 2015-10-01 |
| 12073 | 12073 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 309 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for constipation for 4 of 20 (Residents #3, 11, 15 and 16) sampled residents. The findings included: 1. Review of the facility's Tri-County Healthcare Standing Physician Orders documented, .3. Stool Softener/Laxative: PRN (as needed) Constipation. a. [MEDICATION NAME] S: 1 pill at HS (hour of sleep) prn. b. MOM (milk of magnesia) 30 ml (milliliters) prn. c. [MEDICATION NAME]: 2 tabs (tablet) prn. d. [MEDICATION NAME] tabs: 2 at HS prn. e. [MEDICATION NAME] Suppository 1 PR (per rectum) prn. f. Check for impaction prn and remove if indicated. 4. Enema of choice prn: Severe constipation. 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's BM (bowel movement) Detail option 2 Roster had no BM documented from 10/18/11 through (-) 10/25/11 and from 11/27/11 - 12/1/11. The Medication Administration Record [REDACTED]. The facility failed to implement the physician's standing orders for constipation. 3. Medical record review for Resident #11 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #11's BM Detail option 2 Roster had no BM documented from 2/1/11 - 12/8/11, 1/8/12 - 1/12/12, 1/13/12 - 1/23/12, 1/23/12 - 2/2/12 and 2/12/12 - 2/18/12. The MAR indicated [REDACTED]. 4. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #15's BM - Yes/No (Only) Roster had no BM documented from 2/5/12 - 2/9/12. The facility failed to implement the physician's standing orders for constipation. During an interview in the conference room on 2/23/12 at 10:50 AM, the Director of Nursing (DON) was asked to review Resident #15's bowel movement record. The DON stated, .He (Resident #15) should have received something (for lack of a BM). Expect the nurse to revie… | 2015-10-01 |
| 12074 | 12074 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 314 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Clinical Practice Guidelines, policy review, medical record review and interview, it was determined the facility failed to follow the care plan intervention to turn every two hours to prevent the development of a pressure ulcer for 1 of 3 (Resident #8) sampled residents with pressure ulcers. The findings included: Review of the NPUAP Clinical Practice Guidelines documented, .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours. A written schedule for systematically turning and repositioning the individual should be used. Review of the facility's Skin Program Policy documented, .The nursing department coordinates the response to patient needs.with an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. Medical record review for Resident #8 documented an admission date of [DATE] with readmitted s of 7/18/11 and 8/19/11 and [DIAGNOSES REDACTED]. Review of the care plan documented an approach dated 6/17/11 for Staff to turn and repo (reposition) res (resident) q2hrs (every two hours) and prn (as needed). Review of Weekly Skin Integrity Assessment dated 7/9/11 documented, .Skin Condition Dry. Skin Intact. Review of a nurse's note dated 7/10/2011 documented, .reddened area to buttocks with bluish and blackened areas, with blisters. 2 small opened areas. Review of a nurse's note dated 7/11/2011 documented, .no change to residents buttocks, blistered area still dark discoloration, serosanguenous drainage present. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the DON was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we… | 2015-10-01 |
| 12075 | 12075 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 441 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Association for Professionals in Infection Control and Epidemiology (APIC) Guide to the Elimination of Clostridium difficile in Healthcare Settings, policy review, medical record review, cleaning product efficacy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by utilizing an ineffective cleaning product for 4 of 4 (Residents #8, 14, 19 and 20) sampled residents with Clostridium difficile infection. It was also determined the facility failed to ensure practices to prevent the potential spread of infection when staff members failed to practice sanitary hand hygiene during 1 of 2 dining observations and during catheter care for sampled Resident #6. The findings included: 1. Review of the APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings documented, .Disinfectants commonly used in healthcare settings include quaternary ammoniums and [MEDICATION NAME], neither of which are sporicidal. only chlorine-based disinfectants. kill spores. Review of the facility's Cleaning, Disinfection and Sterilization policy documented, .provide supplies and equipment that are adequately cleaned, disinfected or sterilized. a. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff (Clostridium difficile - an intestinal bacteria which has spores that can live on inanimate objects, such as beds and overbed tables, for up to six months). b. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff. c. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a discharge summary dated 2/23/11 documented, .resident developed [DIAGNOSES REDACTED] at (name of local hospital) .a… | 2015-10-01 |
| 13806 | 13806 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 332 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations and interviews, it was determined the facility failed to ensure 3 of 6 (Nurses #3, 5 and 6) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 5 errors were observed out of 40 opportunities, resulting in a medication error rate of 12.5%. The findings included: 1. Review of the facility's "Administering Medications through a Metered Dose Inhaler" policy documented, "...Allow at least one (1) minute between inhalations of the same medication..." Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 11/29/10 at 11:45 AM, revealed Nurse #3 administered two puffs of a [MEDICATION NAME] inhaler to RR #1. Nurse #3 did not pause between the puffs. Failure to pause at least one minute between the puffs resulted in medication error #1. 2. Medical record review for Resident #6 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #6's room on 11/30/10 at 6:25 AM, revealed Nurse #6 administered one eye into each of Resident #6's eyes. Failure to administer two eye drops into each eye resulted in medication error #2. During an interview on side three on 11/30/10 at 8:20 AM, Nurse #6 stated, "You're right I should have given two drops and I only gave one." 3. Review of the facility's "Insulin Administration" policy documented, "...8. Check the order for the amount of insulin..." Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #16's room on 11/30/10 at 7:15 AM, Nurse #6 performed a fingerstick blood sugar (FSBS) on Resident #16's with results of 12… | 2014-09-01 |
| 13807 | 13807 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 465 | E | 0 | 1 | IDW711 | Based on observations and interviews, it was determined the facility failed to ensure the environment was clean and sanitary as evidenced by a soiled shower chair, a dark brown buildup on the tile, and feces on the drain in the shower stall in 2 of 2 (Shower rooms 1 and 2) shower rooms. The findings included: 1. Observations in Shower #2 on 11/29/10 at 9:35 AM and 3:25 PM and on 11/30/10 at 3:15 PM, revealed a clump of dark brown substance on the drain in the shower stall and a dark brown buildup covering the tile near the drain. During an interview in Shower #2 on 11/30/10 at 3:15 PM, Housekeeper #1 was asked what the dark brown buildup on the tile was and what was the brown substance on the drain. Housekeeper #1 stated, "I don't know what that is on the tile. It has been there for awhile. That's BM (bowel movement) on the drain." 2. Observations in Shower #1 on 11/29/10 at 3:35 PM and on 11/30/10 at 3:15 PM, revealed a bariatric shower chair in the shower stall with the safety belts soiled with brown stains. During an interview in Shower #1 on 11/30/10 at 3:15 PM, the Housekeeping Supervisor was asked if the shower chair was clean. The Housekeeping Supervisor stated, "No and I wouldn't want that belt around me. It's dirty." | 2014-09-01 |
| 13808 | 13808 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 334 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to provide the influenza vaccine for 1 of 22 (Resident #7) sampled residents. The findings included: Review of the facility's "Vaccination of Residents" policy documented, "...Influenza Vaccination... all residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident has already been vaccinated..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 10/7/10 documented, "...Flu vac (vaccine) 0.5 ml (milliliters)..." The facility was unable to provide documentation that the flu vaccine had been administered to Resident #7. During an interview at the side 3 nurse's station on 11/29/10 at 2:40 PM, Nurse #8 was asked if Resident #7 received the flu vaccine. Nurse #8 reviewed the medical record and stated, "...It should have been documented on the MAR (medication administration record), nurse's notes, and care plan. I don't see that. I'm not sure that she got it." | 2014-09-01 |
| 13809 | 13809 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 431 | D | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure a medication cart was locked and medications were not left unattended in 1 of 8 (Side 2 medication cart) medication storage areas. The findings Included: Review of the facility's "Storage of Medications" policy documented, "...The facility shall store all drugs and biological in a safe, secure, and orderly manner... Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological 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..." Observations on side 2 on 11/30/10 at 7:00 AM, revealed the side 2 medication cart was left unattended, unlocked and out of view of the nurse. Observations on side 2 on 11/30/10 at 7:31 AM, revealed a vial of Novolin 70/30 insulin was sitting on top of side 2's medication cart unattended. During an interview on side 2 on 11/30/10 at 7:10 AM, the surveyor told Nurse #6 that she had left the side 2 medication cart unlocked. Nurse #6 stated, "I know it's a bad habit, when I just step right in there (referring to resident's room) I forget." During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nursing stated, "Med (medication) cart should always be locked." | 2014-09-01 |
| 13810 | 13810 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 282 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interviews, it was determined the facility failed to follow interventions on the care plan for floor mats and a pressure relief mattress for 1 of 22 (Residents #5) sampled residents. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 1/27/10 documented, "...pressure relief mattress for comfort and prevention..." and dated 2/25/10 documented, "...low bed with mats in place..." Observations in Resident's #5's room on 11/29/10 at 4:00 PM and on 11/30/10 at 8:30 AM,10:05 AM, 12:05 PM and 2:20 PM, revealed there were no floor mats and a pressure relief mattress in place for Resident #5. During an interview in Resident #5's room on 11/30/10 at 2:40 PM, Nurse #7 verified there were no floor mats or a pressure relief mattress present. During an interview at side 1 nurses' station on 11/30/10 at 2:45 PM, the Director of Nursing confirmed that floor mats and pressure relief mattress were on the care plan but were not implemented for Resident #5. | 2014-09-01 |
| 13811 | 13811 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 309 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to follow physician orders [REDACTED].#17 and 19) sampled residents. The findings included: 1. Medical record review for Resident #17 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered 18 AND CALL MD (Medical Doctor) IF NO RESULTS..." Review of the July 2010 diabetic record for Resident #17 revealed the following BS's above 300 that were not rechecked to determine the results of the insulin administered: a. 7/10/10-4:30 PM, BS-354. b. 7/15/10-4:30 PM, BS-314. c. 7/15/10-8:00 PM, BS-338. d. 7/17/10-11:30 AM, BS-321. e. 7/17/10-8:00 PM, BS-314. f. 7/21/10-11:30 AM, BS-311. g. 7/21/10-8:00 PM, BS-397. h. 7/22/10-11:30 AM, BS-307. i. 7/23/10-4:30 PM, BS-400. j. 7/23/10-8:00 PM, BS-381. k. 7/26/10-8:00 PM, BS-328. l. 7/28/10-4:30 PM, BS-310. m. 7/29/10-7:30 AM, BS-305. n. 7/29/10-8:00 PM, BS-380. o. 7/30/10-8:00 PM, BS-318. During an interview in the conference room on 12/1/10 at 10:45 AM, Nurse #8 stated, "They need to recheck it (BS) to see if the BS has gone down, that's the only way to know the results. Usually recheck it in 45 minutes to an hour unless the doctor has a specific order." 2. Medical record review for Resident #19 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 10/4/10 documented, "...Give Nov ([MEDICATION NAME]) R 15 u now Recheck in 2 hrs (hours) for BS 442..." The physician's orders [REDACTED]." Review of the October 2010 medication administration record (MAR) for Resident #19 documented the following BS results: a. 10/4/10 8 PM BS 441. b. 10/15/10 5:30 PM BS 433. The facility was unable to provide documentation of rechecks in 2 hrs of a BS over 400. Further medical record review revealed a physician's telephone order dated 10/4/… | 2014-09-01 |
| 13812 | 13812 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 280 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interviews, it was determined the facility failed to revise the comprehensive care plan for care of emergency bleeding for 2 of 22 (Resident #18 and 19) sampled residents. The findings included: 1. Review of the facility's "[MEDICAL TREATMENT], [MEDICAL TREATMENT]" policy documented, "...Check graft site for bleeding upon return post-[MEDICAL TREATMENT] and per MD (Medical Doctor) orders. If bleeding occurs, apply direct pressure until controlled. Notify MD and DON (Director of Nursing) if bleeding lasts longer than 30 minutes or is severe initiate EMS (Emergency Management Service) system." 2. Medical record review for Resident #18 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/26/10 documented "[MEDICAL TREATMENT] as ordered. Assess site... q (every) d (day) for s/s (signs and symptoms) inf. (infection) or bleeding assess for thrill/bruit q shift..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 3 nurses' station on 12/1/10 at 1:00 PM, Nurse #9 stated, "(Care plan) says to check for it (emergency bleeding) but doesn't really say what to do for it." 3. Medical record review for Resident #19 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/23/10 documented "...Check shunt or port site for s/s of infections, pain or bleeding daily and PRN (as needed)..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 1 nurses' station on 12/1/10 at 1:52 PM, the DON stated, "It (care plan) should have interventions for a bleed but it wasn't included." | 2014-09-01 |
| 13813 | 13813 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 441 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, observations, and interviews, it was determined 5 of 24 staff members (Certified Nursing Assistants (CNA) #1, CNA #2, Rehabilitation Coordinator, Dietary Manager and Nurse #2) failed to ensure infection control practices were used to prevent the potential spread of infection by not using sanitary hand hygiene or touching food and straws with their bare hands. Two (2) of 6 nurses (Nurses #5 and #6) failed to clean the glucometer with a Super Sani-wipe. The findings included: 1. Review of the facility's "Hand-hygiene" policy documented, "...2. hand washing ...b. after contact ...with non-intact skin... d. before and after eating or handling food... 3. a. before or after direct contact with residents... g. after contact with resident's intact skin... i. after contact with inanimate objects (...equipment) in the immediate vicinity of the resident..." a. Observations in room [ROOM NUMBER] A on 11/30/10 at 7:45 AM, CNA #1 held the toast with his bare hand to put jelly and butter on it. Observations in room [ROOM NUMBER] A on 11/30/10 at 12:15 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands. Observations in room [ROOM NUMBER] B on 11/30/10 at 12:20 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands, opened the straw and touched the straw with her bare hand. b. Observations in room [ROOM NUMBER] on 11/30/10 at 7:18 AM, CNA #2 repositioned a resident, adjusted the bed with the bed control and moved a box under the bed and then began to set up the tray opening the butter and the sweetner. CNA #2 then began to fed the resident. CNA #2 did not wash her hands prior to tray set up or before she fed the resident. Observations in room [ROOM NUMBER] on 11/30/10 at 7:40 AM, CNA #2 did not wash her hands prior to delivery of the meal tray or prior to opening the milk and butter. CNA #2 left the room and proceeded to get the next tray without washing hands. Observations in room [ROOM NUMBER]… | 2014-09-01 |
| 13814 | 13814 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 371 | E | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure that staff had hair and beards covered in the kitchen on 2 of 3 (11/29/10 and 12/1/10) days and that dishes were air dried on 1 of 3 (11/29/10) days of kitchen observations. The findings included: 1. Review of the facility's "DRESS CODE" policy documented, "...B. Dietary staff ...Hair Nets..." Observations in the kitchen on 11/29/10 at 9:00 AM and 1:55 PM, revealed dietary staff #1 working at the ware washer and on the tray line. Dietary staff member #1's beard was not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #1 was working on the tray line with his beard not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #3 stocking supplies in the kitchen. Dietary staff member #3 was wearing a cap that partially covered his hair and his beard was not covered. Observations in the kitchen on 12/1/10 at 8:15 AM, revealed dietary staff members #1 and #3 were in the kitchen with no beard coverings on and dietary staff member #3's hair was partially uncovered. During an interview in the kitchen on 12/1/10 at 8:15 AM, the Dietary Manager (DM) was asked about hair coverings. The dietary manager stated, "They (staff members) wear caps but no beard covers. I don't think our policy says anything about beard covers." The dietary manager agreed that the facial hair was not covered. 2. Review of the facility's "Departmental Policies" documented, "...All pots and pans must be air dried after the final sanitizing rinse..." Observations in the kitchen on 11/29/10 at 9:00 AM, revealed dietary staff member #1 was removing clean dishes from the ware washer and drying the dishes with a towel. Observations in the kitchen on 11/29/10 at 1:55 PM, revealed dietary staff member #2 was removing clean dishes from the ware washer and drying the dishes with a towel. During an interview in the dietary office on 12/1/10 at 8:10 AM, the DM was asked about drying the dis… | 2014-09-01 |
| 2897 | 2897 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 157 | D | 0 | 1 | NDN711 | **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 blood pressure (BP) reading for 1 of 2 (Resident #31) residents of 20 residents in the Stage 2 sample review. The findings included: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the the most recent comprehensive Minimum Data Set (MDS) assessment completed on 4/17/17 revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (0 - 7 equaled severe cognitive impairment) and required either extensive assistance or was totally dependent on staff for the provision of activities of daily living (ADLs) such as transfers, dressing, eating, toilet use, etc. Review of Physician's Orders for (MONTH) (YEAR) revealed Resident #31 was prescribed [MEDICATION NAME] (antihypertensive medication), 15 mg once a day for a [DIAGNOSES REDACTED]. The medication was initiated on 5/26/15. The Physician's orders did not include parameters for holding the medication (not administering when BP was below a specified level). BP measurements were to be taken once a week. Review of Resident #31's BP readings revealed: the following low BP readings documented on the following forms: 5/19/17-82/56 (Blood pressure log) 5/26/17-81/54 (Blood pressure log) 6/9/17-73/49 (Blood pressure log) 6/12/17-78/49 (Nursing Departmental Note) 6/22/17-66/38 (Nursing Departmental Note) There was no evidence the Physician was notified of Resident #31's low BP readings. Review of Doctor's Orders and Progress Notes dated 6/22/17 revealed the Physician was aware of the low BP reading and [MEDICATION NAME] was discontinued on this date. Interview with Licensed Practical Nurse (LPN) #4 on 7/19/17 at 4:49 PM, LPN #4 stated there should be nursing documentation of the low blood pressure readings and notification to the Physician. Interview with the Director of… | 2020-09-01 |
| 2898 | 2898 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 323 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to reassess a resident for the use of siderails and ensure 1 of 1 (Resident #57) residents of the 20 residents on the Stage 2 sample were free from potential accident hazards. The findings included: 1. Review of the facility policy and procedure entitled Safety and Supervision of Residents revised 12/08 revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to minimize the risk of accidents are facility-wide priorities .When accident hazards are identified, the PI (Performance Improvement)/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible .Employees shall be trained and in- serviced on potential accident hazards and how to identify and report accident hazards, and try to minimize risk of avoidable accidents . 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE],documented the resident required total assistance of 2 staff members for bed mobility and transfers. Review o the Task Care Plan for the nursing assistants (NA) identified the resident was to have 2 side rails up when the resident was in bed. Review of a nursing care plan dated 4/3/17 identified the resident was a fall risk .related to cognitive, functional & medical factors as evidenced by impaired safety awareness, poor judgement, weakness, balance instability and fall history . The approaches included to .Re-assess fall risk quarterly & PRN (as needed) .Observe for attempts to get up unassisted . Review of the Departmental Notes dated 7/15/17 documented, the resident was found in bed, with his legs hanging over the side rails. There were no further entries made in the electronic medical r… | 2020-09-01 |
| 2899 | 2899 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 327 | D | 0 | 1 | NDN711 | **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 adequate hydration and maintain fluid balance for 1 of 2 (Resident #31) residents of the 20 residents in the Stage 2 review. The findings included: 1. Review of the facility policy on Nutritional Assessment revised 1/20/14, under the heading of Dietitian indicated the Dietitian was to complete .a. An estimate of calorie, protein and fluid needs . and to determine .b. Whether the resident's current intake is adequate to meet his or her needs . 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician prescribed Comfort Measures and an order not to weigh the resident, both initiated on 8/16/16. Review of the Comprehensive Minimum Data Set (MDS) assessment completed on 4/17/17 revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (0 - 7 equals severe cognitive impairment) and required extensive assistance of 1 staff for eating and drinking. Hydration did not triggered for in depth assessment. Review of the Physician's Orders for (MONTH) (YEAR) revealed Resident #31 was prescribed: [MEDICATION NAME] (diuretic) 20 mg a day initiated for [MEDICAL CONDITION] which increased fluid loss, [MEDICATION NAME] (laxative) 1 capful (17 grams) mixed with liquid daily for constipation, and Boost Plus Energy Drink 4 ounces, 4 times a day to promote nutrition. The annual Nutritional Review, dated 4/7/17 by the Dietitian or Dietary Manager listed the resident's favorite beverages were cranberry juice and sweet tea. The resident was listed as having Dehydration Risk Factors of urinary tract infection, constipation, taking laxative and diuretic medications. No assessment of the resident's fluid needs or fluid intake was found on the assessment. No assessment of the resident's risk for dehydration was noted, even though he … | 2020-09-01 |
| 2900 | 2900 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2017-07-19 | 329 | D | 0 | 1 | NDN711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure that 1 of 6 (Resident #57) residents of the 20 Stage 2 sampled residents was offered non-pharmacological interventions prior to the administration of an anti-anxiety ([MEDICATION NAME]) medication. The findings included: 1. Review of the facility policy entitled Behavioral Assessment and Monitoring revised 4/07 revealed, .The facility will comply with regulatory requirements related to the use of mediations to manage problematic behavior .If the resident is being treated for [REDACTED].will document ongoing reassessments of changes in the individual's behaviors, mood, function .The staff will document (either in the progress notes, behavior assessment forms, or other comparable approaches) about specific problem behaviors . This policy failed to identify non-pharmacological interventions prior to the administration of a medication when indicated. 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 5/28/16 revealed and order for [MEDICATION NAME] 0.5 milligrams (mg) to be administered by mouth every 4 hours as needed (PRN), for increased agitation. Review of the quarterly minimum data set assessment ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview Mental Status (BIMS) score of 7 out of 15 which indicated the resident was severely cognitively impaired. Review of the care plan dated 4/3/17 revealed the resident was at risk for .Mood State; risk for related to cognitive, medical &(and) functional factors as evidenced by confusion, intermittent verbalization of sadness, agitation with sarcasm at times. Need for stimulating activities for optimal cognition, mood and psychosocial health . The approaches identified were .Dx (diagnosis) of anxiety. Administer anxiolytics as ordered for anxiety .Attempt to relieve anxiety/agitation with non-pharmacolog… | 2020-09-01 |
| 5014 | 5014 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2016-04-28 | 425 | E | 0 | 1 | F2H811 | Based on policy review, contract review, observation and interview, the facility failed to ensure the consulting pharmacy provided oversight as evidenced by Schedule II medications not secured by 2 locks in 3 of 5 (South hall, West hall and North hall medication carts) medication storage areas. The findings included: 1. The facility's Controlled Substances policy documented, .Scheduled II (2) Narcotics supply is to be kept under TWO locks at all times . 2. The CONSULTING PHARMACY SERVICES AGREEMENT documented, .DUTIES OF THE CONSULTANT PHARMACIST The following consultation services are required on a regular basis and will be provided on at least a monthly basis as defined below . 4. Meets all other responsibilities required of a consultant pharmacist as set forth in federal, state, and local laws, regulations, or rules . 3. Observations in the south hall medication room on 4/27/16 at 1:43 PM, revealed the south hall medication cart with the following Schedule II controlled medications that were not secured by 2 locks in the bottom drawer: a. Five sleeves of Hydrocodone-Acetominophen 5-325 milligrams (mg). b. Five sleeves of Hydrocodone-Acetominophen 7.5-325 mg. 4. Observations in the west hall medication room on 4/27/16 at 9:30 AM, revealed the west hall medication cart contained the following Schedule II controlled medications that were not secured by 2 locks in the bottom drawer: a. Four sleeves of Hydrocodone-Acetaminophen 5-325 mg. b. One sleeve of Hydrocodone-Acetaminophen 10-325 mg. c. One sleeve of Hydrocodone-Acetaminophen 7.5-325 mg. d. One sleeve of Oxycodone-Acetaminophen 7.5-325 mg. 5. Observations on the north hall on 4/27/16 at 9:30 AM, revealed the north hall medication cart bottom drawer contained the following Schedule II controlled medications that were not secured by 2 locks: a. Six sleeves of Hydrocodone-Acetaminophen 5-325 mg. b. Two sleeves of Hydrocodone-Acetaminophen 7.5-325 mg. c. One sleeve of Hydrocodone 10 mg . 6. Interview with Licensed Practical Nurse (LPN) #1 on 4/28/16 at 9:57 AM, … | 2019-06-01 |
| 5015 | 5015 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2016-04-28 | 431 | E | 0 | 1 | F2H811 | Based on policy review, observation and interview, the facility failed to ensure that medications were stored properly according to the facility's policy when scheduled 2 medications were not secured by 2 locks in 3 of 5 (South hall, West hall and North hall medication carts) medication storage areas. The findings included: 1. The facility's Storage of Medications documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . The facility's Controlled Substances policy documented, .Scheduled II (2) Narcotics supply is to be kept under TWO locks at all times . 2. Observations on the south hall on 4/25/16 at 8:14 AM, revealed the south hall medication cart was locked and unattended. The surveyor was able to reach into the gaps between all 3 large drawers and pull out bubble packs of medications, even though the cart was locked. Interview with Licensed Practical Nurse (LPN) #1 on 4/25/16 at 8:14 AM, on the south hall, LPN #1 was asked if it was safe to be able to pull medications out of the medication cart, even though it was locked. LPN #1 stated, No, never noticed you could do that. Observations in the south hall medication room on 4/27/16 at 1:43 PM, revealed the south hall medication cart contained the following sleeves of controlled medications that were not and could be accessed by unauthorized people due to a gap in bottom drawer of the medication cart: a. Five sleeves of Lorazepam 0.5 milligrams (mg). b. One sleeve of Lorazepam 1 mg. c. Five sleeves of Tramadol 50 mg. d. Four sleeves of Alprazolam 0.25 mg. e. One sleeve of Temazepam 30 mg. f. One sleeve of Clonazepam 1 mg. g. One sleeve of Temazepam 15 mg. h. One sleeve of Lorazepam 1 mg (half tablets). i. One sleeve of Modafinil 100 mg. j. Two sleeves of Lyrica 75 mg. k. One sleeve of Alprazolam 1 mg. The bottom drawer also revealed the following Schedule II controlled medications that were not secured by 2 locks (according to facility policy): a. Five sleeves of Hydrocodone-Acetominophen 5-325 mg. b. Five sleeves of… | 2019-06-01 |
| 6440 | 6440 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 241 | D | 0 | 1 | G89H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to promote care in a manner to enhance and promote dignity and respect when 1 of 16 staff members (Certified Nursing Assistant (CNA) #1) stood over a resident while feeding. The findings included: Observations in room [ROOM NUMBER] on 4/6/15 at 11:25 AM, revealed CNA #1 stood over the resident while feeding. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON's office, the DON was asked if it was acceptable to stand over a resident while feeding. The DON stated, No ma'am. | 2018-08-01 |
| 6441 | 6441 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 323 | D | 0 | 1 | G89H11 | Based on observation and interview, the facility failed to ensure chemicals were stored securely in 1 of 3 (West hall) halls. The findings included: Observations in the west hall on 4/6/15 at 2:30 PM, revealed a mop bucket that contained a mop with a liquid substance in the bucket in the common bathroom. Interview with the Director of Nursing (DON) on 4/7/15 at 8:00 AM, in the west hall, the DON was asked what the liquid substance in the mop bucket was. The DON stated, Well sometimes they leave a bucket to clean up spills, but I don't know if it was water or a cleaning solution. We will have to ask (Named Housekeeping Supervisor). Interview with the Housekeeping Supervisor on 4/7/15 at 8:05 AM, in the west hall beside the resident bathroom, the Housekeeping Supervisor was asked what was the solution in the mop bucket on 4/6/15 that had been left in the resident bathroom. The Housekeeping Supervisor stated, That is a (named solution) cleaning solution we use. We also use this in spray bottles. We keep it (the cleaning solution) locked on our carts. The Housekeeping Supervisor was asked what the difference was to keep it locked up on a cart and unsecured in the resident bathroom. The Housekeeping Supervisor stated, No difference. | 2018-08-01 |
| 6442 | 6442 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 371 | D | 0 | 1 | G89H11 | Based on policy review, observation and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 16 (Certified Nursing Assistants (CNA #1 and 2) staff members failed to perform hand hygiene during dining observations. The findings included: 1. Review of the facility's Hand washing/Hand Hygiene policy documented, .All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . 2. Observations in room 11 on 4/6/15 at 11:25 AM, revealed CNA #1 delivered a meal tray to room 11, the resident requested a straw CNA #1 left the room, went to the medication cart on the west hall and got 2 straws, returned to the room, opened the straw and placed the straw in the glass. CNA #1 placed her left hand on the bed rail, picked up the glass with her left hand and gave the resident a drink. CNA #1 placed her left hand back on the bed rail, used both hands to hold the glass for the resident to take a drink. CNA #1 again placed her left hand on the bed rail, pulled at her uniform top, placed her left hand on the bed rail and with her left hand gave the resident a drink. CNA #1 did not perform hand hygiene. 3. Observations in room 18 on 4/6/15 at 11:35 AM, revealed CNA #2 touched her uniform, pulled the over bed table to the resident's bedside and began to feed the resident without performing hand hygiene prior to feeding the resident. 4. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to touch a bedrail or uniform while feeding a resident without performing hand hygiene. The DON stated, No ma'am. | 2018-08-01 |
| 6443 | 6443 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2015-04-08 | 441 | D | 0 | 1 | G89H11 | **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 2 of 16 (Certified Nursing Assistants (CNA #1 and 2) staff members failed to perform hand hygiene after contact with contaminated sources prior to serving a meal or feeding a resident. The findings included: 1. Review of the facility's Hand washing/Hand Hygiene policy documented, .All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . 2. Observations in room [ROOM NUMBER] on 4/6/15 at 11:25 AM, revealed CNA #1 delivered a meal tray to room [ROOM NUMBER], the resident requested a straw CNA #1 left the room, went to the medication cart on the west hall and got 2 straws, returned to the room, opened the straw and placed the straw in the glass. CNA #1 placed her left hand on the bed rail, picked up the glass with her left hand and gave the resident a drink. CNA #1 placed her left hand back on the bed rail, used both hands to hold the glass for the resident to take a drink. CNA #1 again placed her left hand on the bed rail, pulled at her uniform top, placed her left hand on the bed rail and with her left hand gave the resident a drink. CNA #1 did not perform hand hygiene. 3. Observations in room [ROOM NUMBER] on 4/6/15 at 11:35 AM, revealed CNA #2 touched her uniform, pulled the over bed table to the resident's bedside and began to feed the resident without performing hand hygiene prior to feeding the resident. 4. Interview with the Director of Nursing (DON) on 4/8/15 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to touch a bedrail or uniform while feeding a resident without performing hand hygiene. The DON stated, No ma'am. | 2018-08-01 |
| 8172 | 8172 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 164 | D | 0 | 1 | VR0E11 | Based on policy review, observation and interview, it was determined the facility failed to provide privacy for residents' when forms with resident's names were placed in a trash can instead of being shredded at 1 of 3 (South Side Nurses' Station) nurses' stations. The findings included: Review of facility's Confidentiality of Information . Policy Interpretation and Implementation policy documented, .The facility will safeguard all resident's records, whether medical, financial, or social in nature, to protect the confidentiality of the information . Observations at the south side nurses' station on 1/14/14 at 10:30 AM, revealed a trash can sitting outside the nurse's station next to the shredder and contained lists with residents names on them. During an interview at the south side nurses' station on 1/14/14 at 10:30 AM, Nurse #1 confirmed the papers had residents names. Nurse #1 was asked what their policy was on disposing of resident's information. Nurse #1 stated, .this information should have been shredded . During an interview in the Director of Nursing's (DON) office on 1/15/14 at 9:14 AM, the DON was asked what her expectations were for staff when disposing of resident information or resident rosters were. The DON stated, .a black marker is used to draw through the patient's name when disposing a patient's medication bubble pack and any patient information or rosters should be shredded . | 2017-08-01 |
| 8173 | 8173 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 280 | D | 0 | 1 | VR0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of incidens0, observation and interview, it was determined the facility failed to revise the care plan to reflect new interventions implement after a fall for 2 of 15 (Residents #7 and #93) sampled residents of the 31 residents included in the stage 2 review. The findings included: 1. Review of the facility's Fall Risk Program Introduction For Residents and Families policy documented, .Addressing specific fall causes is the number one way to minimize the severity of fall injuries and frequency of all falls . When assessments have been completed appropriate interventions will be determined, once the risk factors have been identified . Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental and psychosocial well being . 2. Medical record review for Resident #7 documented an admission date of [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Incident Log documented falls on 3/8/13, 4/9/13, 5/15/13, 5/17/13, 6/6/13, 11/14/13 and 12/16/1, with no injuries. Review of the POS [REDACTED].Immediate Post-Incident Action: INSTRUCTED CNA (Certified Nursing Assistant) TO USE RSIDENT'S (Resident's) WALKER FOR ALL AMBULATION AND GAIT BELT FOR ALL TRANFERS (Transfers). Immediate Actions Taken: RESIDENT SHOES REPLACED WITH NONSKID SOLE SHOES AND STAFF INSTRUCTED TO USE WALKER AT ALL TIMES . The care plan dated 6/6/13 did not include these interventions that had been implemented. Observations in Resident #7's room on 1/13/14 at 3:00 PM, 1/14/14 at 8:05 AM and 4:00 PM, revealed Resident #7 seated in a large recliner with a chair alarm in place. During an interview in room [ROOM NUMBER] on 1/14/14 at 4:15 PM, the Minimum Data Set (MDS) Coordinator #… | 2017-08-01 |
| 8174 | 8174 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 371 | D | 0 | 1 | VR0E11 | Based on policy review, observation and interview, it was determined the facility failed to ensure food was dated when opened and used by the best dates on 2 of 3 (1/13/14 and 1/14/14) days of the survey. The findings included: 1. Review of the facility's Food Receiving and Storage policy documented, .Foods shall be received and stored in a manner that complies with safe food handling practices . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . 2. Observations in the walk-in freezer revealed the following: a. On 1/13/14 at 12:45 PM - a bag of unopened corn dogs with no expiration date. b. On 1/13/14 at 12:45 PM and 1/14/14 at 9:35 AM - an opened bag of chicken breasts and an opened bag of Salisbury steaks with no open date or expiration date on the packages. During an interview in the walk-in freezer on 1/14/14 at 9:40 AM, the Certified Dietary Manager (CDM) was asked about the open and expirations dates not being on open packages. The CDM stated, .I don't want to lie and will start putting dates on packages . 3. Observations in the dry storage room on 1/14/14 at 11:35 AM, revealed a large can of Apricots, Fruit Cocktail, Sliced Apples and Mandarin Oranges with no expiration dates. During an interview in the dry storage room on 1/14/14 at 11:40 AM, the CDM was asked about the cans not having expiration dates. The CDM stated, .dates may be on the boxes that the cans are taken out of . | 2017-08-01 |
| 8175 | 8175 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2014-01-15 | 514 | D | 0 | 1 | VR0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined he facility failed to ensure assessments were accurate for 1 of 15 (Resident #7) sampled residents of the 31 residents included in the stage 2 review. The findings included: Medical record review for Resident #7 documented an admission date of [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Monthly Summary forms dated 5/26/13, 6/30/13, 8/25/13, 9/29/13,11/29/13 and 12/28/13 documented Resident #7 with limited range of motion on both sides for upper and lower extremities Review of the Monthly Summary forms dated 6/21/13 and 10/28/13 documented Resident #7 with no limitations in range of motion on both sides for upper and lower extremities. Review of the Monthly Summary forms dated 7/28/13 documented Resident #7 with limitations in range of motion on both sides for upper extremities. During interview at nurses' station #3 on 1/15/14 at 9:05 AM, Nurse #2 was asked about the discrepancies of the range of motion on the monthly summaries. Nurse #2 stated, .(Resident #7) has good days and bad days . should be how they are for the month . | 2017-08-01 |
| 10447 | 10447 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 280 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to revise or update the care plan for [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] safety precautions for 1 of 18 (Resident #14) sampled residents. The findings included: Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised as often as necessary in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental, and psychosocial well being . Medical record review for Resident #14 documented an admission date of [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the hospital history and physical dated 10/22/11 through (-) 11/1/11 documented, .[MEDICAL CONDITION] disorder . Review of the physician's orders [REDACTED].Levetiracetam 500 mg (milligram) take 1 tablet po (by mouth) (sub [MEDICATION NAME]) once a day for [MEDICAL CONDITION] . Review of the care plan dated 10/20/11 and updated 12/12/11 contained no documentation of [MEDICAL CONDITION] disorder or [MEDICAL CONDITION] safety precautions. During an interview in the Minimum Data Set (MDS) office on 12/14/11 at 10:20 AM, the Director of Nursing (DON) was asked to review Resident #14's medical record. The DON stated, .No, there is no [MEDICAL CONDITION] disorder or [MEDICAL CONDITION] safety precautions documented on the care plan . it should include maintain patent airway, stay beside resident until [MEDICAL CONDITION] is over . | 2016-07-01 |
| 10448 | 10448 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 283 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure each resident discharged from the facility had a recapitulation of the resident's stay for 2 of 2 (Residents #16 and 18) discharged residents reviewed. The findings included: 1. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Record of Discharge documented a discharge date of [DATE] and no recapitulation of the resident's stay. 2. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Record of Discharge documented a discharge date of [DATE] and no recapitulation of the resident's stay. 3. During an interview in the Minimum Data Set office on 12/14/11 at 2:40 PM, the Director of Nursing confirmed there is no recapitulation of the resident's stay documented upon discharge. | 2016-07-01 |
| 10449 | 10449 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 309 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow the bowel movement (BM) protocol for 3 of 18 (Residents #2, 15 and 18) sampled residents. The findings included: 1. Review of the facility's BM Policy documented, .If a resident has no bowel movement in 3 days, 3-11 shift will administer laxative per standing order . 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 10/2/11, 10/3/11, 10/4/11, 10/8/11, 10/9/11, 10/10/11, 10/20/11, 10/21/11, 10/22/11, 11/2/11, 11/3/11 and 11/4/11. Review of the MEDICATION RECORD for October and November 2011 had no laxative documented as being given on the third day of no BM on 10/4/11, 10/10/11, 10/22/11 and 11/4/11 as per the facility's policy. During an interview in the Minimum Data Set (MDS) office on 12/14/11 at 11:25 AM, the Director of Nursing (DON) confirmed no laxative had been given on the third day for no BM as per the facility's policy. 3. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 9/7/11, 9/8/11, 9/9/11, 9/10/11, 9/21/11, 9/22/11, 9/23/11, 9/24/11, 9/28/11, 9/29/11, 9/30/11, 10/29/11, 10/30/11 and 10/31/11. Review of the MEDICATION RECORD for September and October 2011 had no laxative documented on the third day of no BM on 9/10/11, 9/24/11, 9/30/11 and 10/31/11 as per the facility's policy. During an interview in the MDS office on 12/14/11 at 11:25 AM, the DON confirmed no laxative had been given on the third day of no BM as per the facility's policy. 4. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE AIDE'S SIGNATURE SHEET had no BM documented on 10/28/11, 10/29/11, 10/30/11 and 10/31/11. Review of the MEDICATION RE… | 2016-07-01 |
| 10450 | 10450 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 323 | D | 0 | 1 | VD1G11 | Based on observation and interview, it was determined the facility failed to maintain safe hot water temperatures in resident areas for 2 of 7 (water heaters #2 and 7) water heaters. The findings included: Observations of the hot water temperatures on 12/12/11 revealed the following: a. Southside resident restroom (water heater #7): 134 degrees Fahrenheit (F) at 9:15 AM. b. Southside shower room (water heater #7): 128 degrees F at 9:35 AM. c. Southside resident restroom (water heater #7): 130 degrees F at 11:20 AM. d. Westside resident restroom adjoining rooms 11 and 15 (water heater #2): 140 degrees F at 1:45 PM. e. Westside resident restroom adjoining rooms 18 and 20 (water heater #2): 120 degrees F at 1:47 PM. f. Westside resident restroom adjoining rooms 11 and 15 (water heater #2): 140 degrees F at 2:25 PM. During an interview on the South-side hall near the beauty shop on 12/12/11 at 9:45 AM, the Maintenance Supervisor was asked about the hot water temperatures. The Maintenance Supervisor confirmed that safe water temperature for resident use should be below 120 degrees F and the water heater settings are adjusted at the individual water heaters supplying each hall. | 2016-07-01 |
| 10451 | 10451 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2011-12-14 | 328 | D | 0 | 1 | VD1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure residents received proper treatment for [REDACTED].#10 and 14) sampled residents receiving oxygen therapy. The findings included: 1. Review of the facility's Care Plan Policy documented, .Care plans should be reviewed and revised as often as necessary in order to reflect the resident's current status. Goals and interventions should be conveyed that will help the resident attain or maintain the highest practicable level of physical, mental, and psychosocial well being . 2. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification orders signed 12/8/11 documented Oxygen (O2) at 3 liters per minute (L/M). Review of the care plan dated 10/27/11 documented no interventions for oxygen. Observations in Resident #10's room on 12/12/11 at 12:00 PM, 2:40 PM, 5:05 PM and on 12/13/11 at 8:45 AM and 10:50 AM, revealed Resident #10 receiving O2 at 2L/M. The oxygen was not being administered at the physician's prescribed rate of 3 L/M During an interview at nurse's station #3 on 12/14/11 at 10:35 AM, Nurse #2 was asked about the care plan for O2. Nurse #2 confirmed that Resident #10 had an order for [REDACTED]. 3. Medical record review for Resident #14 documented an admission date of [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's 24 Hour Skilled Nursing Documentation Sheet dated 12/1/11 through 12/13/11 documented, .Oxygen continuous 2- (to) 3 liter/minutes 98% O2 Sat (saturation) . Review of the care plan dated 10/20/11 and updated 12/12/11 contained no documentation of oxygen therapy. Observations in Resident #14's room on 12/12/11 at 9:15 AM and 2:50 PM and on 12/14/11 at 8:40 AM, 9:15 AM and 10:55 AM, revealed Resident #14 lying in bed receiving O2 at 2 L/M. During an interview in… | 2016-07-01 |
| 13127 | 13127 | ALAMO NURSING AND REHABILITATION CENTER | 445467 | 580 W MAIN STREET | ALAMO | TN | 38001 | 2010-09-15 | 441 | D | 0 | 1 | JZLH11 | **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 1 of 5 nurses (Nurse #1) washed her hands to prevent the potential spread of infection. The findings included: Review of the facility's "Treatment/Wound Cleansing/Dressing changes" policy documented, "...14. Cleanse wound well ...16. ...remove your dressing field and throw in double bag garbage along with your gloves. 17. Wash hands..." Observations in Random Resident (RR) #1's room on 9/14/10 at 9:05 AM, revealed Nurse #1 cleansed the wound on RR #1's left heel with 4 by (x) 4's and wound cleanser. Nurse #1 applied [MEDICATION NAME] and the new dressing. Nurse #1 did not wash her hands between cleaning the wound and application of the medication and the new dressing. During an interview on the south hall 9/14/10 at 9:20 AM, Nurse #1 was asked why she did not wash her hands after cleaning the wound. Nurse #1 stated, "I never have done that (wash hands after cleansing the wound) before..." | 2015-05-01 |
| 1808 | 1808 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2017-04-26 | 157 | D | 0 | 1 | 6ADV11 | **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 medication recommendation by a consulting practitioner for one resident (#101) of 29 residents reviewed. The findings included: Resident #101 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 13 points out a possible 15 points. Medical record review of the Behavioral Medicine Progress Note dated 2/07/17, revealed Reason for Visit (Chief complaint): f/u (follow-up) medication review for recent consult to initiate trazadone (antidepressant medication also used to treat [MEDICAL CONDITION]) r/t (related to) [MEDICAL CONDITION]. Medical record review of the facility Order Summary Report dated 4/05/17 revealed no order for the resident to receive [MEDICATION NAME]. Interview with the Director of Nursing on 4/25/2107 at 4:00 PM, in the conference room, confirmed the physician had not been notified of the recommendation from the Behavioral Medicine Progress Note for [MEDICATION NAME], and no order had been written. | 2020-09-01 |
| 1809 | 1809 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2019-06-05 | 880 | D | 0 | 1 | K47S11 | **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 for 1 resident (#52) of 3 residents observed for wound care. The findings include: Review of the facility policy Clean Dressing Change revised 12/09, revealed .Put on gloves .Remove soiled dressing, place in bag for disposal .Remove/dispose of gloves, wash hands, don clean gloves .Clean wound as ordered .Remove/dispose of gloves, wash hands, don clean gloves .Apply dressing and secure .Remove gloves .Wash hands . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Orders revealed the following: 5/16/19 - [MEDICATION NAME] Powder (medication to treat wound) Apply .every day shift for wound care clean daily with iodine x 3 rinse with (normal saline) x 3 pat dry, apply collagen granules (medication to treat wound) to base of wound bed with (a wound dressing) cover with waterproof silicone dressing. 5/31/19 - Santyl Ointment (medication to debride wound) Apply to areas of slough (dead tissue) .topically every day shift. Observation of Resident #52's wound care on 6/5/19 at 10:15 AM, with the Wound Care Nurse (WCN) in the resident's room, revealed the WCN removed the soiled dressing from the resident's coccyx; removed and discarded the gloves; donned new gloves and did not wash the hands. Continued observation revealed the WCN disinfected the wound with iodine, removed the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN rinsed the wound with a 4 x 4 dressing soaked with normal saline, dried the wound, discarded the gloves and donned new gloves without washing the hands. Continued observation revealed the WCN applied Santyl ointment to the wound, discarded the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN applied the co… | 2020-09-01 |
| 1810 | 1810 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2018-06-19 | 880 | D | 0 | 1 | KGE111 | Based on facility policy review, observation, and interview, the facility failed to ensure staff disinfected hands after glove removal and disinfect hands after the administration of medication for 1 of 3 nurses observed for medication administration. The finding included: Review of the facility policy, Hand Hygiene, last revised 2/2018, revealed Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene .using an alcohol based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient .after removing gloves . Observation of a medication administration on 6/18/18, at 8:05 AM, in the 300 hallway, revealed Licensed Practical Nurse (LPN) #1 had prepared the resident's medication in a plastic medication cup. Continued observation revealed the following: 1. LPN entered the resident's room, gave the medication cup to the resident. 2. Resident swallowed several pills at at time. 3. Resident dropped 1 medication pill on the floor. 4. LPN donned gloves, picked up the 1 medication pill off the floor, removed the gloves with the pill inside the gloves, placed on bedside table. 5. LPN donned another pair of gloves, administered an insulin injection. 6. LPN removed the gloves, exited the room, returned to the medication cart without disinfecting the hands. Interview with LPN #1 on 6/18/18, 8:20 AM, in the 300 hallway, confirmed hands were not disinfected after glove removal nor after the administration of the insulin injection | 2020-09-01 |
| 4680 | 4680 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-08-09 | 312 | D | 1 | 0 | 6ZST11 | **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 provide showers per the care plan for 1 Resident (#5), of 4 residents reviewed for Activities of Daily Living, of 5 residents reviewed. The findings included: Review of the facility policy, Routine Resident Care revised (MONTH) 2008, revealed .Residents receive necessary assistance to maintain good grooming and personal .hygiene .Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed . 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 with a Brief Interview of Mental Status Score of 15/15 (cognitively intact), had no symptoms of [MEDICAL CONDITION], and was dependent for transfers, bathing, and personal hygiene. Medical record review of the current Care Plan revealed Resident #5 was to receive showers twice weekly on Wednesdays and Saturdays. (An average of 8 showers monthly). Medical record review of the Activity of Daily Living (ADL) Flow Sheets dated 6/30/16 to 7/30/16 revealed the resident was not showered on Wednesdays and Saturdays in accordance with the Care Plan, and received only 3 showers in a 30 day period between 6/30/16 to 7/30/16. No showers were documented as performed between 7/16/16 and 7/30/16 (14 consecutive days). Observation and interview with Resident #5 on 8/9/16 at 5:00 PM, in the resident's room, revealed the resident was alert, oriented to place and circumstances. The resident reported he did not regularly receive showers on Wednesdays and Saturdays and reported he frequently was not offered showers on his appointed shower days. Continued observation and interview revealed a noticeable smell of body odor present. The resident also reported the facility frequently delayed his showers. Resident #5 stated he could not recall when he las… | 2019-08-01 |
| 4944 | 4944 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 225 | D | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to notify the State Survey and Certification Agency of an allegation of abuse for 1 resident (#22) of 3 residents reviewed for an allegation of abuse of 42 residents reviewed. The findings included: Review of facility policy, Abuse & Neglect Prohibition, revised 6/13 revealed .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing .The facility will report all allegations and substantiated occurrences of abuse .to the state agency .as designated by state law . 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 the resident scored an 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderately impaired cognitive skills. Medical record review of the significant change of status MDS dated [DATE] revealed the resident scored 14 on the BIMS indicating the resident was independent with daily decision making. Review of a facility investigation dated 3/7/16 .in regards to the 'incident' on (MONTH) 3: With that being said, this is a recount of (Resident #22's) experience: It started off that the blinds were closed and couldn't see outside, so I leaned over to look outside (and my bed was up how I like it). I fooled around and my legs came off the bed, so I pushed the button to get help. So this guy came in and put my legs back on and said that I've messed up again. After that, he came to the end of the bed and started messing with my controls and putting my bed down. I asked what he was doing and he told me I couldn't have my bed up. I've been here for [AGE] years and never been told that. He lowered the bed and said 'I'll fix it so you can't ever … | 2019-06-01 |
| 4945 | 4945 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 253 | D | 0 | 1 | EMXX11 | Based on review of facility policies, review of facility cleaning schedule, observation, and interview, the facility failed to maintain clean window draperies for 1 room of 28 rooms observed and to maintain safe and sanitary rooms for 4 of 28 rooms observed. The findings included: Review of facility policy, Drapery & (and) Cubicle Curtain Maintenance, release date 4/05 revealed .Cubicle curtains are cleaned when visibly soiled .draperies are vacuumed at least quarterly, and laundered or dry cleaned .to remove dust, soil, and foreign matter . Review of the Repair Requisition, undated revealed .communicate needed repairs to maintenance and the Administrator . Review of the (YEAR) Project Schedule, undated revealed .Sun (Sunday)-Bed Rails .Mon (Monday)-AC vents . Observation with the District Manager for Housekeeping and Laundry on 4/18/16 at 10:47 AM, in a semi-private room on the 200 Hallway revealed dust debris and grime on the window draperies. Further observation revealed behind B bed the baseboard on the floor with the wheels of the bed on top of the baseboard. Continued observation revealed the chair rail with splintered wood shards behind B bed. Further observation revealed drywall peeling away on the wall surrounding the heat/air conditioning unit (ac). Observation with the Maintenance Director on 4/18/16 at 11:00 AM, on the 300 Hallway of a semi-private room revealed cracks in the drywall surrounding the heat/ac unit. Continued observation in another semi-private room on the 300 Hallway revealed the chair rail laying on the floor behind 2 resident beds. Observation with the Maintenance Director on 4/18/16 at 11:15 AM, on the 100 Hallway in a semi-private room revealed peeling drywall on the walls around the heat/ac unit. Interview with the Maintenance Director on 4/18/16 at 3:20 PM, on the 200 Hallway confirmed the facility did not keep a log of laundered or cleaned draperies, was not aware of the splintered chair rail on the 200 Hallway, the fallen chair rail in the 300 Hallway room, and confirmed the fac… | 2019-06-01 |
| 4946 | 4946 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 281 | J | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Nursing (YEAR) Drug Handbook, facility policy review, medical record review, review of a Medication Variance Report, review of the Individual Patient's Controlled Substances Record, and interview, the facility failed to ensure the correct dosage of a medication for 1 resident (#22) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Resident #22 in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on (MONTH) 25, (YEAR) at 10:50 AM, in the DON's office. The Immediate Jeopardy is effective 3/17/16 and is ongoing. The findings included: Review of the Nursing (YEAR) Drug Handbook revealed .Traditionally, nurses have been taught the 'five rights' of medication administration. These are broadly stated goals and practices to help individual nurses administer drugs safely .The right dose: Verify that the dose and form to be given is appropriate for the patient, and check the drug label with the prescriber's order . Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitt… | 2019-06-01 |
| 4947 | 4947 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 309 | J | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, Controlled Drug Record review, and interview, the facility failed to administer scheduled pain medication prior to wound care for 2 (#150, #169) residents of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Residents #150 and #169 in Immediate Jeopardy (A situation which the provider's noncompliance has caused or is likely to cause serious harm, injury, impairment or death). The Administrator and the Director of Nursing were informed of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the Director of Nursing's office. The Immediate Jeopardy was effective from 3/17/16 and is ongoing. The findings included: Review of facility policy, Medication Administration, revised 4/08 revealed .Resident Medications are administered in an accurate .timely .manner .records the name, dose, route, and time .on the Medication Administration Record [REDACTED] Review of facility policy, Pain Management, revised 8/12 revealed .The goal of the Pain Management Program is that pain is identified and treated effectively and consistently .be proactive to make sure the resident achieves relief and remains free from pain .The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration . Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Pain Evaluation dated 12/14/15 revealed .[DIAGNOSES REDACTED].Facial Wound .how much time have you experienced pain or hurting over the last 5 days .Frequently . Medical record review of the Non Pressure Skin Condition Record dated 12/15/15 and signed by wound care nurse revealed .wound to (right) jaw (and) partial mouth (second to) gunshot wound .Has severe pain . Medical record review of a physician's orders [REDACTED].Start ([MEDICATION NAME]) 1… | 2019-06-01 |
| 4948 | 4948 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 314 | D | 0 | 1 | EMXX11 | **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 notify the Registered Dietician timely of the development of a pressure ulcer for 1 (#22) of 3 residents reviewed for pressure ulcers of 42 residents reviewed. The findings included: Review of facility policy, Skin Management, revised 8/12 revealed .A Registered Dietician will assess all residents identified with skin impairment for nutritional status in a timely manner . 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 Braden Scale-For Predicting Pressure Sore Risk dated 1/21/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the Weekly Pressure Ulcer Record revealed an unstageable pressure ulcer on the sacrum with a date of onset 3/15/16, measured 4.1 cm (centimeters) x (by) 2.2 cm x 1.2 cm. Continued review of the Weekly Pressure Ulcer Record dated 3/15/16 revealed .has draining non-stageable pressure ulcer to sacrum-moderate serosanguineous fluid noted. Large portion of measured area (approx (approximately) 75% (percent)) is slough-remaining tissue red, purple & (and) black . Medical record review of a Medical Nutritional Therapy Review, prepared by the Registered Dietician (RD) dated 3/31/16 revealed .resident feeds himself. PO (by mouth) recorded as only approximately 50% from dietary. However, he has soda at bedside and a refrigerator in his room. Has continued to refuse to be weighed on hospital return despite multiple attempts by multiple people. Obviously has large nutrient needs for wound healing. Has Stage III pressure wound to coccyx .Will add Vit (vitamin) C, zinc sulfate to the [MEDICATION NAME] Vit he is already receiving and additional a.a. (amino acid) to aid in wound healing . Observation on 4/20/16 at 10:45 AM revealed the wound care nurse providing … | 2019-06-01 |
| 4949 | 4949 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 333 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of Medication Variance Report, and interview, the facility failed to prevent significant medication errors for 7 (#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed 7 (#22, #150, #169, #178, #31, #93, #177) residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on [DATE] at 10:50 AM in the DON's office. The Immediate Jeopardy is effective [DATE] and is ongoing. The facility was cited F 333 at a scope and severity of (K), which constitutes Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration, revised ,[DATE] revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], after admission to the hospital after and an overdose of [MEDICATION NAME] sulfate at the facility, with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) Physician's Recapitulation Orders revealed .[MEDICATION NAME] (opiate narcotic [MEDICATION NAME], can cause respiratory distress and death when taken … | 2019-06-01 |
| 4950 | 4950 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 353 | E | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents in a timely manner for 7 residents (#22, #2, #17, #61, #26, #176, #7) of 20 interviewable residents who were dependent for needs of 42 residents reviewed. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's significant change in status assessment Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was independent with daily decision making, required extensive assist of 2 persons required with bed mobility and toileting. Interview with Resident #22 on 4/21/16 at 1:00 PM, in the resident's room revealed it often took a long time for the call light to be answered on all shifts. Continued interview revealed the resident usually needed to use the bedpan or be removed off the bedpan when the call light was pressed. Continued interview with Resident #22 revealed the staff would tell him they needed another person working. Continued interview revealed often it was approximately 1 hour before assistance was obtained to be removed from the bedpan. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's annual MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, was totally dependent with 2 person assist required with transfer, dressing, and personal hygiene. Interview with Resident #2 on 4/21/16 at 1:15 PM, in the resident's room revealed the resident had given up 1 of her 3 a week showers because the facility did not have enough staff at times. Continued interview revealed the staff would tell her there was … | 2019-06-01 |
| 4951 | 4951 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 441 | E | 0 | 1 | EMXX11 | **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 medications in a sanitary manner for 1 Resident (#26) of 30 observed opportunities, failed to provide meal services in a sanitary manner for 2 residents on 2 halls of 4 halls observed, and failed to follow physician's orders [REDACTED].#99) of 1 resident observed for isolation precautions. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in .sanitary manner .Follow sanitary practices . Review of facility policy, Hand Hygiene, dated 2012 revealed .To decrease the risk of transmission of infection by appropriate hand hygiene .Handwashing .the most important single procedure for preventing healthcare associated infections .after providing care to a resident . Review of facility policy, Contact Precautions, dated 2012 revealed .use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment .Hand hygiene should be completed prior to donning gloves .Gloves should be worn when entering the room .Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately .Contact Precautions .Multi-drug resistant organisms . Observation on 4/18/16 at 8:50 AM, during medication administration on the 100 Hall revealed Licensed Practical Nurse (LPN) #7 dropped a pill on top of the medication cart, picked up the pill with bare hands, placed the pill in the medication cup with the resident's other medications, and administered the medication to Resident #26. Interview with LPN #7 on 4/18/16 at 8:52 AM, on the 100 Hall confirmed she dropped the pill on top of the medication cart, then picked up the pill, placed the pill in the medication cup with the resident's other … | 2019-06-01 |
| 4952 | 4952 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 490 | K | 0 | 1 | EMXX11 | Based on medical record review, review of the Medication Variance Record and interview, the facility failed to be administered in a manner to ensure significant medication errors did not occur for 7 residents (#22, #150, #169, #178, #31, #93, #177) and failed to ensure pain medication was administered prior to wound care for 2 residents (#150, #169) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occur placed all residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 1:24 PM, in the conference room confirmed the Administrator had not been involved in the process related to medication errors. Refer to F281 (J), F309 (J), F333(K). | 2019-06-01 |
| 4953 | 4953 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 501 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Services Agreement, facility policy review, review of facility investigations, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of resident care policies to ensure Physician orders [REDACTED]. The facility's failure placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on (MONTH) 25, (YEAR) at 10:50 AM in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited Substandard Quality of Care at F309 (J), F333 (K). The findings included: Review of the Medical Director Services Agreement revealed .Duties & (and) Responsibilities of Medical Director .Coordinate medical care in the Facility to insure the adequacy and appropriateness of the medical services provided, for example: Assist the Administrator and Director of Nurses in clinical program development and act as a consultant to the Director of Nurses in matters relating to resident care . Interview with the Medical Director on 4/25/16 at 10:35 AM, in the conference room revealed when asked what recommendations the Medical Director had made to the facility related to medication errors the Medical Director replied the nurses needed to be accountable for their mistakes and What other people do is out of my hands. Refer to F 281 (J), F309 (J) F333 (K), F 490 (K), F 520 (K) | 2019-06-01 |
| 4954 | 4954 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 514 | E | 0 | 1 | EMXX11 | **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 a complete and accurate medical record for 6 residents (#22, #178, #169, #17, #150, #125) of 42 residents reviewed. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record [REDACTED]. Review of facility policy, [MEDICAL CONDITION] Management, dated 2012 revealed .in accordance with state regulation: the Licensed Nurse will institute the appropriate Behavior Monitoring form associated with the drug category .To identify/target behaviors .document number of episodes of behaviors . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner's (NP) order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] (opiate antidote) 1.6 mg (milligram) IM (intramuscular injection) now .[MEDICATION NAME] 1mg IM again now . Medical record review of a NP order dated 3/18/16 at 11:00 AM revealed .Give 2 mg [MEDICATION NAME] now. Medical record review of the 3/18/16 through 3/31/16 Medication Record revealed no documentation the resident had received the [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 4/18/16 at 8:40 AM, in the DON's office confirmed there was no documentation on the 3/18/16 through 3/31/16 Medication Record the resident had received any [MEDICATION NAME] on 3/18/16. Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/18/16 at 10:05 AM revealed LPN #1 had administered the [MEDICATION NAME] 1.6 mg IM to the resident on 3/18/16. Interview with the facility's Wound Care Nurse on 4/18/16 at 10:30 AM, in the DON's office revealed the Wound Care Nurse had administered [MEDICATION NAME] 1 mg IM and [MEDICATION NAME] 2 mg to Resident #22 on 3/18/16. Continued interv… | 2019-06-01 |
| 4955 | 4955 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2016-04-25 | 520 | K | 0 | 1 | EMXX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the Quality Assurance (QA) Committee failed to identify and develop plans of action to ensure physician orders [REDACTED].#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occurr placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F-490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 11:00 AM, in the DON's office confirmed the QA Committee had not identified medication errors as a problem. Further interview confirmed the facility failed to ensure the nurses were following the physician orders [REDACTED]. Interview with the Administrator on 4/25/16 at 11:05 AM in the DON office confirmed pain was identified as a problem but the QA Committee did not develop a plan of care to identify the residents not getting medications as ordered. Further interview confirmed the facility did not develop an audit to identify specific medications or audit medications administered and to ensure the medications were administered as ordered. Refer to F281 (J), F309 (J), F333 (K), F490 (K), F501 (K), F520 (K) | 2019-06-01 |
| 6518 | 6518 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2015-04-15 | 315 | D | 0 | 1 | VLFE11 | **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 an individualized bladder re-training program for 1 resident (#106) of 3 residents reviewed for incontinence, of 29 residents reviewed. The findings included: Review of the facility policy, Bowel and Bladder Management, revision date (MONTH) 2012, revealed, .when a resident is identified as incontinent, he/she will be evaluated .and if appropriate, bowel and/or bladder re-training program is indicated .bowel and bladder reports from Care Tracker will be monitored for a 7-day period to establish voiding/bowel movement patterns and assist with establishing the Plan of Care. Medical record review of the behavioral medicine note dated 4/3/15 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 the resident was assessed as always continent and the Brief Mental Status Interview (BIMS) score 15/15, indicating resident was cognitively intact. Medical record review of the Evaluation for Bowel and Bladder Training dated 12/26/14 revealed no incontinence of bladder or bowel. Continued review of Evaluation for Bowel and Bladder Training dated 3/25/15 revealed occasionally incontinent. Comments: pad to bed for occ incontinence. Plan for mangagement: check for occasional urinary incontinent episodes walker @ bedside for (Independent) I toileting. Medical record review of the Quarterly MDS dated [DATE] revealed the resident was assessed as occasionally incontinent and the BIMS score 15/15 indicating resident was cognitively intact. Medical record review of the Custom Catch Report dated 3/28/15-4/14/15 revealed the resident had 7 episodes of incontinence between the hours of 10 PM and 6 AM. Medical record review revealed no documentation a bladder re-training program had been developed for the resident. Observation and intervi… | 2018-07-01 |
| 8649 | 8649 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 164 | D | 0 | 1 | IFG311 | Based on observation and interview, the facility failed to ensure the privacy of one resident (#7) during one of two medication administration passes observed. The findings included: Observation with Licensed Practical Nurse (LPN) #2 on February 10, 2014, at 8:45 a.m., on the 100 hallway, revealed LPN #2 prepared medications at the medication cart, using the Medication Administration Record [REDACTED]. Continued observation revealed LPN #2 left the MAR indicated [REDACTED]. Interview with LPN #2 on February 10, 2014, at 8:57 a.m., in the hallway, confirmed the resident's information on the MAR indicated [REDACTED]. | 2017-05-01 |
| 8650 | 8650 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 242 | D | 0 | 1 | IFG311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accommodate preferences for one resident (#67) of thirty residents reviewed. The findings included: Resident #67 was readmitted 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 out of 15 on the Brief Interview for Mental Status exam indicating the resident was cognitively intact. Continued interview revealed the resident required extensive assistance from two persons for activities of daily living and personal hygiene, and was totally dependent with assistance of two persons for transfers. Review of the Mental and Behavioral Health Visit Notes dated November 25, 2013, January 7, 2014, and January 21, 2014, revealed, .wants to get up and out of .room to distract .and help .cope but says staff don't always follow through on getting .up .really needs to get out of .room occasionally because the isolation is feeding .depression .states has asked to get up and out of .room but staff can't seem to find the time .feels discouraged and defeated . Medical record review of the physicians recapitulation orders dated February 1 through February 28, 2014, revealed, .Up in chair daily; out of bed daily as per pt (patient) request . Observation on February 11, 2014, at 10:30 a.m., and February 12, 2014, at 10:00 a.m., in the resident's room, revealed the resident was in bed. Observation and interview with the resident in the resident's room, on February 11, 2014, at 10:30 a.m., confirmed the resident required assistance and the use of a lift for transfers to get out of the bed. Continued interview confirmed the resident had not been able to get out of the bed as often as desired due to not enough staff to get me up. Stated, I am aware of the extra time and attention it takes to get me up because of my size and having to use the lift. They (staff) tell me they will … | 2017-05-01 |
| 8651 | 8651 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 253 | D | 0 | 1 | IFG311 | Based on observation and interview, the facility failed to keep the hallways free of odors for two of four hallways. The findings included: Observation during the survey from February 10-12, 2014, of the one hundred hallway, revealed unpleasant, foul odors. Continued observation revealed the unpleasant, foul odors were in two rooms on the 100 hall. Interview with the Director of Nursing on February 12, 2014, at 8:55 a.m., in one of the rooms on the 100 hall, confirmed was aware of the rooms having unpleasant, foul odors due to the facility not able to regularly clean the air mattress used for the residents in the room. Continued interview revealed the resident in one room (private room) was aware of the odor and had asked the facility to hang cloves in the room to help with the odors. Observation during the survey from February 10-12, 2014, revealed the three hundred hallway had a foul odor, and appeared to be from one room. Continued observation revealed the odor was a strong urine smell. Interview with Licensed Practical Nurse #1 on February 12, 2014, at 9:40 am, in the three hundred hallway, confirmed the smell was urine smell coming from the room. | 2017-05-01 |
| 8652 | 8652 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 279 | D | 0 | 1 | IFG311 | **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 for one resident (#67) with concerns of not getting out of bed; one resident (#13) for [MEDICAL TREATMENT] access; and one resident (#73) for [MEDICAL CONDITION] for a total of three of thirty residents reviewed. The finding included: Resident #67 was readmitted 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 out of 15 on the Brief Interview for Mental Status exam indicating the resident was cognitivelly intact. Continued review revealed the resident required extensive assistance from two persons for activities of daily living and personal hygiene, and was totally dependent with assistance of two persons for transfers. Review of the Mental and Behavioral Health Visit Notes from the Licensed Clinical Social Worker (LCSW) dated November 25, 2013, January 7, 2014, and January 21, 2014, revealed, .want to get up and out of .rooom to distract .and help .cope but says staff don't always follow through on getting .up .really needs to get out of .room but staff can't seem to find the time .feels discouraged and defeated . Medical record review of the physician's recapitulation orders dated February 1 through February 28, 2014, revealed, .Up in chair daily; out of bed daily as per pt (patient) request . Medical record review of the care plan dated October 4, 2013, revealed the physician's orders [REDACTED]. Observation on February 11, 2014, at 10:30 a.m., and on February 12, 2014, at 10:00 a.m., in the resident's room, revealed the resident was in the bed. Observation and interview with the resident, in the resident's room, on February 11, 2014, at 10:30 a.m., confirmed the resident required assistance and use of a lift for transfers to get out of the bed. Continued interview confirmed the resident had not been able to get out of the bed… | 2017-05-01 |
| 8653 | 8653 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2014-02-12 | 441 | D | 0 | 1 | IFG311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to change soiled clothing for one resident (#13) of thirty residents reviewed, and failed to prevent cross-contamination during ice pass for two of two ice passes observed. The findings included: Observation on February 11, 2014, at 10:15 a.m., of resident #13 resting in bed, revealed a large dark spot on the resident's gown. Continued observation revealed the dark spot was located on the left side just above the waistline, and was irregular in shape, measuring approximately two inches by two inches. Continued observation revealed the spot appeared to be dried blood. Continued observation revealed the resident had a dialysis access in the left upper arm. Interview with resident #13 on February 11, 2014, at 10:15 a.m., in the resident's room, confirmed the resident had gotten blood on the gown from the dialysis treatment the day before (February 10, 2014). Continued interview confirmed the resident returned to the facility between 5:00 p.m. and 6:00 p.m. Interview with the Director of Nursing on February 12, 2014, at 12:59 p.m., in the Activities room, confirmed the soiled gown was to be changed when the resident returned to the facility on [DATE]. Observation on February 12, 2014, at 7:30 a.m., on the 100 hallway, revealed certified nurse aide (CNA) #5 retrieved a water glass from room [ROOM NUMBER], held the glass over the ice container, filled the glass with ice from the container, and returned the glass to the resident's room. Continued observation revealed CNA #5 repeated this practice for another resident in room [ROOM NUMBER] before leaving the hallway. Interview with CNA #5 on February 12, 2014, at 12:55 p.m., confirmed the resident's water glass was not to be held over the ice container while filling the glass with ice. Interview with the Director of Nursing on February 12, 2014, at 12:55 p.m., confirmed the resident's water containers were not to be held over the ice container w… | 2017-05-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );