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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3752 | 3752 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2017-02-15 | 151 | D | 1 | 0 | C72111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure resident rights were honored without interference for 1 resident (#6) of 3 residents review for resident rights of 8 sampled residents. Review of the facility policy Patients' Rights, undated, revealed .Privacy-Knock on doors before entering, do not enter while you are knocking, wait for response . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimal (MDS) data set [DATE] revealed Resident #6's Brief Interview Mental Status (BIMS) score was 15 (cognitively intact). Review of a facility investigation dated 2/6/17 at 11:20 AM revealed Resident #6 reported Licensed Practical Nurse (LPN) #5 violated his personal rights by entering his room after he told the LPN to wait. Interview with Registered Nurse (RN) #5 on 2/14/17 at 2:25 PM, in the conference room, revealed LPN #5 came to her (RN #5) office on 2/6/17 and reported .she (LPN #5) had just walked in on the resident and his girlfriend having sex .asked (LPN #5) if she had knocked before entering .she said she had and the resident replied hold on a minute .asked (LPN #5) if she had waited before she (LPN #5) entered the room and she replied no . Further interview revealed RN #5 informed LPN #5 the resident . did have the right to privacy . Interview with Resident #6 on 2/14/17 at 2:45 PM, in his room, revealed .I do not know what her (LPN #5) deal was .I told her to hold on a minute .I knew I had rights . Interview with the Risk Manager on 2/15/17 at 11:45 AM, in the conference room, confirmed Resident #6's rights were violated and the facility failed to follow facility policy. | 2020-02-01 |
| 4245 | 4245 | THE WATERS OF UNION CITY , LLC | 445138 | 1105 SUNSWEPT DR | UNION CITY | TN | 38261 | 2016-09-29 | 151 | D | 0 | 1 | 1KSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to honor resident's rights to have personal items in their room for 4 of 59 (Resident # 64, 7, 41, and 33) residents. The findings included: 1. The facility's Your Resident Rights and Protections under State and Federal Law policy documented, .Personal Property .You have the right to keep and use your personal belongings and property . 2. Medical record review revealed Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) dated of 8/29/16 documented Resident #64 had a Brief Interview of Mental Status (BIMS) score of 14 and was cognitively intact. The care plan dated 9/13/16, revealed there were no documentation of safety concerns. Interview with Resident #64 on 9/20/16 at 8:33 AM, in Resident #64's room, Resident #64 stated, .(named Director of Nursing (DON)) came in and pulled all of my deodorant, hair spray, and lotion from my drawer yesterday and took them to his office .I didn't like that .(named DON) said they don't want them in here . 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #7 had a BIMS score of 15 which indicated she was cognitively intact. Observations at facility all 12 days revealed Resident #7's door was closed at all times unless staff was in the room. Interview with Resident #7 on 9/20/16 at 1:32 PM, in Resident #7's room, Resident #7 stated, .those two women (named Human Resources Clerk and RN #5) came in last night and confiscated my 3 shower gels, 2 1/2 bottles of cologne, hair spray, all of my cosmetics, eye brow pencil, rouge .stated I could keep my lip stick if I keep it where they, nobody can see it .eye glass cleaner, 2 pairs of scissors, crochet hooks .so I couldn't crochet last night, which is what I like to… | 2019-10-01 |
| 8416 | 8416 | THE WATERS OF ROBERTSON, LLC | 445137 | 104 WATSON ROAD | SPRINGFIELD | TN | 37172 | 2013-09-26 | 151 | E | 0 | 1 | 6APT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the facility's smoking schedule, medical record review and interview, it was determined the facility failed to honor resident rights to smoke for 3 of 5 (Random Resident (RR) #2, 3 and 4) interviewable random residents that smoke. This finding was related to a substantiated allegation in a complaint investigation initiated on 9/10/13. The findings included: 1. Review of the facility's Smoking Policy documented, .Every resident who desires to smoke is permitted to do so if the center's interdisciplinary team has determined that the practice would be safe for the resident . 2. Review of the facility's SMOKING SCHEDULE DATED 7/25/13 documented, .9:00 A (AM), 10:30 A, 1:30 P (PM), 4:00 P, 7:00 P, 9:00 P . with the persons or department responsibility listed for each smoke time. 3. Medical record review for RR #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses CLINICAL HEALTH STATUS dated 9/6/13 documented RR #2's short term and long term memory was marked as .OK (okay) .Additional notes . She was oriented to room and surroundings; instructed to call for assistance as needed . During an interview in RR #2's room on 9/10/13 at 7:35 PM, RR #2 confirmed that she does smoke but she is unable to walk and is dependent on staff to get her out of the bed. RR #2 stated, .smoke time was 7 PM, I turned my light on for them to come to get me up so I could go smoke. I can't walk, I broke my hip . RR #2 was asked how her light got turned off. RR #2 stated, I cut my light on at 6:45 PM (for the 7:00 PM smoke time) and no one came. My light was turned off right before you came in. They finally came in here and got me off the bed into the wheelchair (wc) but I missed the smoke break . During an interview in the conference room on 9/10/13 at 3:00 PM, the Administrator confirmed that residents were allowed to smoke. The Administrator stated, It's their right . During an interview in the confere… | 2017-06-01 |
| 12001 | 12001 | GRACE HEALTHCARE OF CORDOVA | 445218 | 955 GERMANTOWN PKWY | CORDOVA | TN | 38018 | 2011-07-07 | 151 | D | 0 | 1 | ZND511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the meals service time for the 100 hall, observation and interview, it was determined the facility failed to honor a residents' right to rise and dress at her designated time in the morning for 1 of 29 (Resident #25) sampled residents observed. The findings included: Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].@ (at) 4:00 - (to) 5:00 AM DAILY. Review of a list of Resident Requests on Resident #25's chart documented, (Resident) is asking that we meet her following requests: Personal care completed and up in chair after breakfast everyday. Review of the meal service time for the 100 hall documented, .BREAKFAST .100 HALL - 7:30 A (AM). Observations in Resident #25's room (room [ROOM NUMBER]) on 7/5/11 at 9:45 AM and 7/7/11 at 10:45 AM, revealed Resident #25 was still in bed. During an interview in Resident #25's room on 7/5/11 at 9:45 AM, Resident #25 was asked what was the latest time she would like to get up after breakfast. Resident #25 stated, . 9:00 (AM). During an interview in the conference room on 7/7/11 at 8:00 PM, Resident #25's attending physician was asked what time Resident #25 should be gotten up in the morning. Resident #25's attending physician stated, .Should do what the resident wants. | 2015-10-01 |
| 12097 | 12097 | MEADOWBROOK NURSING CENTER | 445443 | 1245 E COLLEGE ST | PULASKI | TN | 38478 | 2011-03-24 | 151 | F | 0 | 1 | OSFO11 | Based on the group interview, it was determined the facility failed to ensure each resident had the right to exercise their choice of time when getting up in the morning when 3 of 8 Random Residents (RR) #3, 4 and 5) attending the group interview voiced that the facility staff got them up for breakfast. The facility had a census of 63 residents. Sixty two of the 63 residents residing in the facility received a breakfast tray. The findings included: During the group interview in the therapy room on 3/21/11 at 3:00 PM, the group was asked if the facility had rules about what time residents had to get up in the morning. Three alert and oriented residents made the following statements: a. RR #3 stated, yes there was a getting up time. b. RR #4 supported RR #3's statement by saying they had to get up for breakfast. c. RR #5 stated, .we have to get up. the night shift helps (getting resident up in the morning). | 2015-10-01 |
| 12734 | 12734 | LAURELBROOK SANITARIUM | 4.4e+201 | 114 CAMPUS DRIVE | DAYTON | TN | 37321 | 2012-08-03 | 151 | D | 1 | 0 | 9S9K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility records, review of local Election Commission records, observation, and interview, the facility failed to provide State and County candidate information to ensure informed voting choices for one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment, with a score of fifteen out of fifteen. A score of fifteen revealed the Resident's cognition was intact. Medical record review of an Activity Progress Note dated July 12, 2012, at 4:08 p.m., revealed the Resident had heard an announcement about Election Commission and voting (Absentee Voting, scheduled to occur at the facility on July 12, 2012, at 9:30 a.m.). Continued review revealed, "...(Resident) said (Resident did not know who to vote for. I (Activity Coordinator) told (Resident) I had a list but (Resident) had to give me some time to finish something that I was doing at that moment. A few minutes later I brought the...list of information about the event. (Resident) was still upset because (Resident) never got enough information about the elections..." Medical record review of an Activity Progress Note dated July 13, 2012, at 2:36 p.m., revealed the Activity Department provided a local newspaper which contained information about local candidates. Review of a facility document dated June 4, 2012, revealed information to register Resident #1 was submitted to the Election Commission by the Activity Coordinator. Review of an Election Commission notice to vote, (no date), addressed to the facility, informed the facility the Absentee Voting Deputies would be at the facility on Thursday, July 12, 2012, at 9:30 a.m., "...to vote your registered Residents..." Observation and interview of the Resident, in the Sun Room,… | 2015-08-01 |
| 14312 | 14312 | TRI STATE HEALTH AND REHABILITATION CENTER | 445263 | 600 SHAWANEE RD | HARROGATE | TN | 37752 | 2010-03-31 | 151 | D | J54J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor the rights of one resident (#12) of twenty-three residents reviewed. The finding's included: Resident # 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was independent in decision making and had no short or long term memory problems. Observation and interview on March 29, 2010, at 11:45 a.m., and March 30, 2010, at 8:15 a.m., in the resident's room revealed the resident awake and resting in bed with bilateral half side rails in the down position. Continued observation and interview with resident on these dates revealed, the resident wished to have the side rails up for increased safety but had been told by Licensed Practical Nurse (LPN) #1 that side rails in the up position were illegal. Interview on March 30, 2010, at 8:20 a.m., in the resident's room, with LPN #2 confirmed it was the resident right to have side rails in the up position. Interview on March 30, 2010, at 8:32 a.m., with LPN #1 on the 200 hall revealed, LPN #1 told the resident that, side rails could be up when Certified Nursing Assistants (CNA's) were in the room but side rails were to be down when staff were not in the room. Continued interview with LPN #1 revealed, the facility's Risk Manager had informed LPN #1 of the above. Interview on March 30, 2010, at 8:45 a.m., with the facility's Risk Manager, in the Risk Manager's office revealed, the Risk Manager had told LPN #1 that the resident was to have side rails when CNA's were in the room to assist in turning; but was not to have the side rails in place in the up position when staff was not in room. Continued interview confirmed, that it was the resident right to have side rails in the up position. | 2014-01-01 | ||
| 6184 | 6184 | THE STRATFORD HOUSE | 445205 | 8249 STANDIFER GAP ROAD | CHATTANOOGA | TN | 37421 | 2015-09-04 | 152 | D | 1 | 0 | SRXG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to inform the resident's designated Power of Attorney and obtain consent for administration of a vaccine for one resident (#9) of 15 residents reviewed. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Power of Attorney dated and signed by the resident on 5/20/13, revealed the resident appointed his daughter as his .attorney in fact the full power and authority to authorize medical treatment for [REDACTED]. Medical record review of the Informed Consent for Pneumococcal Vaccine dated 4/7/15, revealed the resident signed the consent himself with no documentation the POA was informed. Medical record review of the Minimum (MDS) data set [DATE] revealed the resident had severe cognitive impairment and required assistance with all activities of daily living. Interview with the Registered Nurse, who obtained the resident's consent and administered the vaccine, on 8/6/15 at 11:45 AM, in the conference room, confirmed the POA was not contacted prior to administering the pneumonia vaccine. | 2018-09-01 |
| 13890 | 13890 | TRENTON CENTER | 445308 | 2036 HIGHWAY 45 BYPASS | TRENTON | TN | 38382 | 2011-04-28 | 152 | D | 1 | 0 | M8B211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 705 Based on medical record review, it was determined the facility failed to ensure the resident's rights were exercised by the legally appointed individual for 1 of 5 (Resident #1) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Power of Attorney (POA) dated 9/1/09 documented the resident had appointed an individual to make decisions for any type of medical treatment. Review of the physician's orders [REDACTED].#1 was receiving hospice care. | 2014-08-01 |
| 4844 | 4844 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2016-06-30 | 153 | D | 0 | 1 | UFS611 | Based on record review and interview, the facility failed to provide requested release of information of a resident's medical records timely in accordance with facility policy for 1 resident (#25) of 2 residents reviewed for requests of information, of 41 residents reviewed. Findings include: Medical record review revealed Resident #25's POA (Power of Attorney) filled out an Authorization for Release of Information signed and dated on 1/15/16. Continued review revealed the Authorization for Release of Information was also signed and dated by facility nursing staff as Signature of Witness on 1/15/16. Record review indicated the facility office logged the request for information on 1/20/16 and dated given to POA on 1/21/16, which was 4 business days after the request was made on 1/15/16. Review of the facility policy titled Health Information Management Policy & Procedure Manual, Chapter 6, page 46, confirmted If a current resident or their legal representative requests copies, notify the (legal department) by telephone, and then comply with providing the records within two working days. Interview with Licensed Nurse #3 on 6/29/16 at 5:20 PM confirmed requests for release of information are faxed to the facility corporate office and the medical records should be released to the family or power of attorney within 2 business days as specified in the facility policy. | 2019-07-01 |
| 8391 | 8391 | LIFE CARE CENTER OF GRAY | 445479 | 791 OLD GRAY STATION ROAD | GRAY | TN | 37615 | 2014-07-09 | 153 | D | 1 | 0 | 145111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a Authorizaton of Release of Information, review of facility policy, review of a postal ship date, and interview, the facility failed to ensure a resident received copy of a medical record timely after submission of a written request for one resident (#1) of sixteen residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of an Authorization of Release of Information dated December 20, 2013, revealed the resident had submitted in writing a request for a copy of the entire medical record. Review of facility policy, Release of Information, revealed .Requested copies should be provided within two working days (excluding weekends and/or holidays) unless state law mandates a shorter period . Review of a postal ship date for the requested medical record revealed a ship date of January 24, 2014, and a delivery date of January 28, 2014 (thirty-nine days after the request date). Interview with the Medical Records Clerk on July 1, 2014, at 11:14 a.m., in the facility conference room confirmed the facility had failed to follow it's own policy after the written request for medical records. C/O # | 2017-07-01 |
| 8942 | 8942 | LIFE CARE CENTER OF CROSSVILLE | 445167 | 80 JUSTICE ST | CROSSVILLE | TN | 38555 | 2014-03-24 | 153 | D | 1 | 0 | SQ5811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation, review of a Concern and Comment form, review of an authorization for release of information, review of shipping labels, and interview, the facility failed to provide requested medical records in a timely manner for one resident (#9) of three residents reviewed. The findings included: Review of an undated facility policy titled, Chapter 6: Confidentiality, Release of Information, and HIPPA (Health Insurance Portability and Accountability Act) revealed, .Handling a Request for Copies of Medical Records. The request should be put in writing on an Authorization for Release of Information form and signed by the resident or personal representative .should specifically state which records are to be copied .To comply with federal regulations, the copies must be made within two business days .Note: The maximum turnaround time to respond to a valid request for a discharged or expired resident's information is 30 days from the date of the request unless otherwise required by state law . Medical record review revealed the resident (#9) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident's responsible party was a relative. Review of a Concern & Comment Form dated [DATE], revealed, .describe in detail your Concern, Comment .Request for records. Were you able to report his concern .Yes. If yes, please provide the staff member's name (Administrator) . Review of a Facility Investigation and Response form dated [DATE], revealed, .explained process and advised (resident's reponsible party) to request through HIM (Health Information Management) at (responsible party's) .convenience .since the patient was discharged release of records needed to go through corporate and could take up to 30 days . Review of an Authorization for Release of Information dated [DATE], revealed the resident's responsible party requested … | 2017-03-01 |
| 8982 | 8982 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2013-10-10 | 153 | D | 0 | 1 | F4M111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to allow the legal representative to purchase a copy of medical records for one resident (#98) of thirty-one residents reviewed. The findings included: Resident #98 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of medical records revealed resident #98 was transferred to a hospital on [DATE], at 7:10 a.m., after the resident was found unresponsive. The resident was discharged from the facility on [DATE], after the family removed all personal belongings from the resident's room. Medical record review of a nurse's note dated [DATE], revealed, .Family here and wanted copy of medical records . Interview with the Power of Attorney (POA) on [DATE], at 8:35 a.m., by telephone, revealed the facility refused to allow the POA to purchase a copy of the medical records. Interview with an attorney representing a family member of eesident #98 revealed, My client's (parent) is deceased and my client has asked for the medical records and the facility refused. I have also sent three letters to the facility with requests for copies of the medical records and the facility has not acknowledged my letters. Interview with the Administrator by telephone on [DATE], at 5:05 p.m., confirmed, I am not going to give my records to anyone unless they go through my attorney. complaint # | 2017-03-01 |
| 13590 | 13590 | ST BARNABAS NURSING HOME | 445008 | 950 SISKIN DRIVE | CHATTANOOGA | TN | 37403 | 2011-07-28 | 153 | D | 1 | 0 | UMD211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to allow access to the medical record for one resident #3 of 8 residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory and the resident's decision making skills were not able to be scored. Continued review of the MDS revealed the resident was non-ambulatory and required assistance for all activities of daily living. Interview with the Durable Power of Attorney (DOPA) on July 27, 2011, at 4:15 p.m., by phone revealed the facility would not allow the DOPA for health care, to review the medical records for Resident #3. Continued interview with the DOPA revealed there had been a difference of opinion about the resident's care which was provided by the resident's physician. Interview with the Director of Nursing (DON) on July 26, 2011, at 3:30 p.m., in the conference room confirmed the DOPA, who is a Physician, had asked to review the medical record. When the DON heard the DOPA wanted to review the chart, there was hesitation about allowing the DOPA (Physician) to review the chart alone. This was later accomplished after receiving a phone call from the POA's attorney. The DOPA was allowed to review the resident's medical record with a staff present but failed to meet the within 24 hour request time frame. C/O # | 2014-11-01 |
| 13969 | 13969 | JEFFERSON CITY HEALTH AND REHAB CENTER | 445246 | 283 W BROADWAY BLVD | JEFFERSON CITY | TN | 37760 | 2009-08-19 | 153 | D | 1 | 0 | 7WTY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide copy of a resident medical records in a timely manner after requested for one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Tracking HIPPA Privacy Request and Response log revealed the resident's spouse (Power of Attorney) had requested a copy of the medical records on August 4, 2009.Continued review revealed no documentation the request had been processed. Telephone interview with the Director of Nursing on August 19, 2009, at 1:45 p.m., confirmed the request had not been completed as requested on August 4, 2009. c/o tn 518 | 2014-07-01 |
| 1955 | 1955 | LIFE CARE CENTER OF BRUCETON-HOLLOW ROCK | 445326 | 105 ROWLAND | BRUCETON | TN | 38317 | 2017-06-21 | 154 | D | 0 | 1 | ZIWL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to inform a resident of the risks and benefits of receiving an antianxiety medication and obtain consent prior to administration for 1 of 5 (Resident #80) sampled residents reviewed for unnecessary medication use. The findings included: The facility's Policies for Medication Administration documented, .Patient consents will be obtained prior to the administration of any new and/or changed psychopharmacologic medications . Medical record review revealed Resident #80 had admission physician orders [REDACTED]. There was no Psychoactive Medication Informed Consent form in the medical record indicating Resident #80 had been informed of the risks and benefits of taking [MEDICATION NAME] prior to administration and no signed consent form for receiving the anti-anxiety medication. Review of the PRN (As needed) Administration Record for (MONTH) (YEAR) indicated the [MEDICATION NAME] was administered 10 times. Review of the physician orders [REDACTED]. Review of the PRN Administration Record for (MONTH) (YEAR) indicated the [MEDICATION NAME] was administered 3 times without Resident #80 providing consent and being informed of the risks and benefits. Review of the physician's orders [REDACTED]. Interview with the Social Services Assistant #1 and the Social Services Director in the Social Services office on 6/20/17 at 3:05 PM, revealed the nurses obtain the resident's medication consent forms on admission. When asked when the consent form should be obtained, they stated, Would hope as soon as possible. The Social Services Assistant #1 stated it should be done shortly after the medication was in place. Interview with the Assistant Director of Nursing (ADON) #1 on 6/20/17 at 3:20 PM in the ADON office, ADON #1 confirmed the medication consent form should have been obtained on admission. She stated they reviewed all consents in the building, one hall per week. ADON #1 confirme… | 2020-09-01 |
| 4137 | 4137 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2016-11-03 | 154 | J | 1 | 0 | J51L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to inform the responsible party/Power of Attorney of a change in the treatment when a 60 cubic centimeter syringe was used to force feed food and liquid for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders revealed an order on [DATE] for a pureed (blenderized food) diet. Continued medical record review revealed no physician orders from admission to discharge, to syringe feed Resident #1. Medical record review of the Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed Resident #1's diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, … | 2019-11-01 |
| 12729 | 12729 | LAURELBROOK SANITARIUM | 4.4e+201 | 114 CAMPUS DRIVE | DAYTON | TN | 37321 | 2012-05-15 | 154 | D | 1 | 1 | G6LS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to inform one resident (#1) of a laboratory test performed of twenty-seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) indicating intact cognitive skills and no memory impairment. Interview with the Nursing Home Administrator (NHA) on May 7, 2012, at 1:50 p.m., in the NHA office, revealed a urine drug screen was completed on the resident on May 3, 2012, without the resident's knowledge or consent. Interview with the Director of Nursing (DON) on May 9, 2012, at 9:10 a.m., in the front lobby, confirmed the facility completed a urine drug screen on the resident without the resident's knowledge or consent. C/O # # | 2015-08-01 |
| 918 | 918 | NHC HEALTHCARE, HENDERSONVILLE | 445191 | 370 OLD SHACKLE ISLAND RD | HENDERSONVILLE | TN | 37075 | 2017-06-28 | 155 | D | 1 | 1 | QJYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on patient rights review, medical record review, and interview, the facility failed to allow 1 Resident (#59) of 32 residents reviewed the right to refuse dental services. The findings included: Review of the Patient Rights handbook provided to each resident in the facility revealed, .You have the right to accept or refuse any medication or treatment .You are entitled to explore various options available to you and to choose the treatment option you prefer . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Telephone interview with Resident #59's family conservator on 6/28/17 at 12:53 PM revealed she had revoked her consent for dental care in (YEAR). Continued interview revealed she had verbalized this to the Social Worker (SW) who stated she would call the dental office and tell them to take the resident off the list to be seen at the facility. Continued interview revealed the family conservator learned the resident received dental services on 1/5/17 after receiving a bill from the dental clinic. She called the facility and spoke with the SW and was told she would call the dental clinic again and make sure the resident was no longer on the list for cleanings or any further dental care. Medical record review revealed a Dental Progress Note dated 1/5/17 indicating that a dental exam, cleaning, and x-rays had been completed by the dental clinic for Resident #59. Interview with the SW on 6/28/17 at 2:05 PM in the classroom confirmed the family conservator had requested no dental services to be performed for the resident. Continued interview revealed the resident was placed on the exam list by the dental clinic in error, and the resident did receive dental services on 1/5/17. The SW stated, I just overlooked her being on the list when he showed it to me. The SW confirmed the facility failed to honor the resident's right to refuse dental services. | 2020-09-01 |
| 3307 | 3307 | NEWPORT HEALTH AND REHABILITATION CENTER | 445504 | 135 GENERATION DRIVE | NEWPORT | TN | 37821 | 2017-05-24 | 155 | D | 0 | 1 | 8GYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of medical records, and interview, the facility failed to ensure advance directives for appropriate care and treatment were identified in the resident's record for 1 (#142) of 27 residents reviewed. The findings included: Review of the facility policy, Advance Directives, revision date 2/2017, .the resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive .specific instructions on the types of treatment .or withheld .maintained in the resident's clinical record . Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Record, dated 2/9/17, revealed, Do Not Resuscitate - DNR (Do Not Resuscitate). Medical record Review of the POS [REDACTED]. Medical record Review of the POS [REDACTED]. Continued review revealed treatment requested included antibiotics, intravenous fluids, and feeding tube. Medical record review of an APN-BC (Advanced Practice Nurse-Board Certified) Progress Note dated 4/18/17 revealed comfort care - the patient is a DNR with no intubation and wants comfort measures only. Interview with the Director of Nursing (DON) on 5/23/17 at 5:00 PM, in the conference room, confirmed the facility was responsible for a valid POST/POLST. Further interview confirmed the resident's record contained 2 opposing POSTS/POLST regarding resuscitation. Interview continued and confirmed the medical record contained no physician order for [REDACTED]. Interview with the Administrator on 5/23/17 at 6:50 PM, in the conference room, confirmed the facility failed to ensure Resident #142's advance directives were clearly documented in the resident's medical record. | 2020-09-01 |
| 3717 | 3717 | SIGNATURE HEALTHCARE OF FENTRESS COUNTY | 445362 | 208 DUNCAN ST N | JAMESTOWN | TN | 38556 | 2017-03-28 | 155 | J | 1 | 0 | Q88111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to administer Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 resident (Resident #6) of 6 resident deaths sampled, of 13 residents reviewed for advanced directives. The facility's failure to honor Resident #6's Advance Directives status resulted in Resident #6 not receiving CPR on [DATE] and dying, placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions were validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-155, the facility is not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR), undated, revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support (maintenance of airway, breathing, circulation) if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tenne… | 2020-03-01 |
| 3784 | 3784 | STARR REGIONAL HEALTH & REHABILITATION | 445277 | 886 HWY 411 NORTH | ETOWAH | TN | 37331 | 2017-02-22 | 155 | D | 1 | 0 | IXF411 | **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 honor resident rights to refuse administration of a medication for 1 resident (#1) of 10 residents reviewed. The findings included: Review of the facility's policy titled Refusal of Treatment dated (MONTH) 2013, revealed .Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician .The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Medical record review of the physician's orders [REDACTED]. Medical record review of a nursing progress note dated 11/6/16, written by Licensed Practical Nurse (LPN) #2, revealed .new order for [MEDICATION NAME] 5 mg IM was received and given . Further review of the progress notes revealed LPN #2 documented [MEDICATION NAME] 5 mg IM was administered at 9:50 PM. Review of the note, documented by LPN #2, revealed the resident's response to the medication was .Still mad .refusal of meds . Review of a facility investigation witness statement dated 11/7/16, completed by the Occupational Therapist (OT), revealed the resident reported to the OT .after dinner he (Resident #1) was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported he was getting upset and said 'I'll take my pills but you are not giving me a shot.' (Resident #1) reported the nurse stated 'you're going to take that shot no matter what . Review of the facility's investigation revealed an interview was co… | 2020-02-01 |
| 4138 | 4138 | MT PLEASANT HEALTHCARE AND REHABILITATION | 445374 | 904 HIDDEN ACRES DR | MOUNT PLEASANT | TN | 38474 | 2016-11-03 | 155 | J | 1 | 0 | J51L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to honor the Advanced Directives for a resident with swallowing and aspiration risks for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Physician order [REDACTED].Do Not Attempt Resuscitation, Comfort Measures-Relieve pain and suffering .Use oxygen, suction, and manual treatment of [REDACTED]. was signed by the resident's Power of Attorney and the Medical Director on [DATE]. Medical review of the Speech Therapy (ST) Evaluation and Plan of treatment dated [DATE] revealed Resident #1 had .Clinical S/S (signs and symptoms) of Dysphagia (difficulty swallowing): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. The treatment plan further revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by the [DATE] discharge, was tolerating pureed diet while fed by staff, caregiver/staff educated on safe swallowing strategies including bite/sip, small bites, positioning. The swallowing treatment training included small bites/sips (,[DA… | 2019-11-01 |
| 4621 | 4621 | MAJESTIC GARDENS AT MEMPHIS REHAB & SNC | 445150 | 131 N TUCKER | MEMPHIS | TN | 38104 | 2016-06-09 | 155 | D | 0 | 1 | RCPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's list of staff certified in Cardiopulmonary Resuscitation (CPR) and interview, the facility failed to ensure CPR staff were available for 4 of 14 ([DATE] 11 PM-7 AM, [DATE] 11 PM-7 AM, [DATE] 7 PM-7 AM, and [DATE] 11 PM-7 AM) days. The findings included: The facility's Daily Assignment Sheet dated [DATE] revealed there was no CPR certified staff on the 11 PM - 7 AM shift. The facility's Daily Assignment Sheet dated [DATE] revealed there was no CPR certified staff on the 11 PM - 7 AM shift. The facility's Daily Assignment Sheet dated [DATE] revealed there was no CPR certified staff on the 7 PM - 7 AM shift. The facility's Daily Assignment Sheet dated [DATE] revealed there was no CPR certified staff on the 11 PM - 7 AM shift. In an interview with the Director of Nursing (DON) on [DATE] at 10:38 AM, in the conference room, the DON was asked if the facility should be staffed at all times with personnel that is certified in CPR. The DON stated, Yes. | 2019-08-01 |
| 4652 | 4652 | WHITEHAVEN COMMUNITY LIVING CENTER | 445233 | 1076 CHAMBLISS ROAD | MEMPHIS | TN | 38116 | 2016-06-28 | 155 | D | 0 | 1 | N42U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's list of staff certified in Cardiopulmonary Resuscitation (CPR), record review and interview, the facility failed to ensure CPR certified staff were available for all shifts for 7 of 30 shifts from [DATE] through [DATE]. The findings included: Review of the list of the facility staff certified in CPR and the working schedule revealed there was no one certified in CPR scheduled to cover the following shifts: a. [DATE] - 7 AM to 7 PM and 11 PM to 7 AM b. [DATE] - 7 AM to 7 PM and 11 PM to 7 AM c. [DATE] -11 PM to 7 AM d. [DATE] - 7 PM to 7 AM e. [DATE] - 7 PM to 11 PM. Interview with the Regional Director of Operations (RDO) on [DATE] at 7:15 PM, in the conference room, the RDO confirmed that not all shifts had staff that were certified in CPR. | 2019-08-01 |
| 5528 | 5528 | CLARKSVILLE MANOR NURSING CENTER | 445455 | 900 PROFESSIONAL PARK DRIVE | CLARKSVILLE | TN | 37040 | 2015-11-05 | 155 | D | 0 | 1 | 4Z6811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure staff honored advance directives as evidenced by Cardiopulmonary Resuscitation (CPR) being performed on a resident with a Do Not Resuscitate (DNR) status for 1 of 33 (Resident #228) residents included in the stage 2 review. The findings included: The facility's advance directive policy documented, .Adult patients are informed and written information provided regarding the right to accept or refuse medical or surgical treatment and, at the individual's option, formulates an advance directive . The patient's right of self-determination of withholding resuscitative services will be respected . Should the patient show signs of cardiopulmonary arrest, the clinician will follow the CPR order . Medical record review revealed Resident #228 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of Right Lower Extremity, Malignant Neoplasm of Bladder, Anxiety, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED] Fibrillation, Gout, [MEDICAL CONDITION], Urinary Incontinence, History of [MEDICAL CONDITION], Cerebral Infarction Without Residual Deficits, Hypertension, and [DIAGNOSES REDACTED]. A Tennessee Physician order [REDACTED]. documented, .CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing . (checkmark) Do Not Attempt Resuscitation (DNR/no CPR) (Allow Natural Death) . The Basis for These Orders Is . (checkmark) Patient's preferences . The electronic Medication Administration Record [REDACTED].Advance Directives . Do Not Resuscitate . A hospital History and Physical form dated [DATE] documented, .CODE STATUS . DNR . A nurse's note dated [DATE] at 4:15 AM documented, .Called to resident's room r/t (related to) unresponsiveness. CPR performed. A nurse's note dated [DATE] at 4:25 AM documented, Resident observed to be unresponsive by staff at 0200 am this morning. At this current time the computer systems were down and the staff were … | 2019-02-01 |
| 5879 | 5879 | FOUR OAKS HEALTH CARE CENTER | 445458 | 1101 PERSIMMON RIDGE RD | JONESBOROUGH | TN | 37659 | 2015-10-14 | 155 | D | 0 | 1 | IC5J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident rights, medical record review, and interview, the facility failed to allow a resident (#35) to refuse treatment for [REDACTED]. The findings included: Review of Resident Rights-Integrity Healthcare of Jonesboro-LLC, revealed .B.Notice of rights and services .4. The Resident has the right to refuse treatment . Medical record review revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 15 indicating the residnet was cognitively intact. Interview with Resident #35 on 10/12/15 at 11:32 AM, in the resident's room revealed approximately 1 month ago (September) at 4:00 AM, staff woke her up and held her down to obtain a blood sample. Continued interview revealed the staff member was a nurse, CNA (Certified Nursing Assistant) and the outsource laboratory technician. The resident stated had refused to have the blood drawn. Continued interview with the resident revealed this had made the resident mad. The resident stated she normally has blood drawn from the right arm, and the staff had taken the blood sample from the left, causing bruises. Medical record review of a facility investigation dated 9/2/15 revealed the resident had 2 bruises, 1 on the left forearm and 1 on the left hand as a result of the attempt and the actual blood sample had been drawn. Interview with Resident #35 on 10/13/15 at 1:50 PM and again on 10/14/15 at 9:00 AM, revealed the resident remembered the staff holding her against her will to obtain the blood specimen. During each interview the resident stated had made her mad that staff did not listen to her and how they (staff) had caused the bruises to her left arm and hand. Interview with the Assistant Director of Nursing (ADON) on 10/14/2015 at 6:50 AM, in the Director of Nursing's office confirmed the resident had been… | 2018-11-01 |
| 6410 | 6410 | FAYETTEVILLE HEALTH AND REHABILITATION CENTER | 445320 | 4081 THORNTON TAYLOR PARKWAY | FAYETTEVILLE | TN | 37334 | 2015-04-15 | 155 | E | 0 | 1 | WJ8M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the facility's list of staff certified in Cardiopulmonary Resuscitation (CPR), record review and interview, the facility failed to ensure CPR certified staff were available for 4 of 14 (Monday, Tuesday, Wednesday and Sunday for 6 PM to 6 AM) shifts per week. The findings included: The facility's Emergency Procedure - Cardiopulmonary Resuscitation policy documented, Policy Statement . Personnel have completed training on the initiation of Cardiopulmonary Resuscitation / Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] . Policy Interpretation and Implementation . If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . Preparartion for cardiopulmonary Resuscitation . Obtain and/or maintain . certification in Basic Life Support / Cardiopulmonary Resuscitation . Select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION] . Review of the list of the facility staff certified in CPR and the schedule revealed there was no one certified in CPR scheduled to cover the 6 PM to 6 AM shift for Monday, Tuesday, Wednesday and Sunday. Review of the facility pharmacy orders dated [DATE] revealed 20 residents currently in the facility had a code status for CPR. Interview with the Administrator and the Director of Nursing (DON) on [DATE] at 10:34 AM, confirmed that there is no staff scheduled in the facility that is CPR certified on Monday, Tuesday, Wednesday and Sunday from 6 PM to 6 AM. The Administrator and the DON confirmed the facility policy does require staff members to be certified in CPR/BLS. | 2018-08-01 |
| 7897 | 7897 | THE WATERS OF UNION CITY , LLC | 445138 | 1105 SUNSWEPT DR | UNION CITY | TN | 38261 | 2014-09-24 | 155 | J | 1 | 0 | EQWV11 | Deficiency Text Not Available | 2017-09-01 |
| 9001 | 9001 | LIFE CARE CENTER OF EAST RIDGE | 445296 | 1500 FINCHER AVENUE | EAST RIDGE | TN | 37412 | 2014-03-24 | 155 | D | 1 | 0 | WKUE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility documentation review, and interview, the facility failed to ensure the resident's right to refuse treatment was honored for one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident scored fourteen of fifteen on the Brief Interview for Mental Status assessment indicating the resident was cognitively intact and able to make decisions. Review of the facility's investigative documentation dated February 10, 2014, revealed two staff members reported being present in the resident's room and had observed the nurse administering medications insist the resident take medication, after the resident declined. Continued review revealed the resident requested not to take the medication, stating it made the resident sick. Continued review revealed the nurse continued to coax the resident into taking the medication, which eventually the resident did, against the resident's wishes. Review of the facility's admission criteria, Section 11: Resident's Rights, .5. The Resident has the right to give consent and to refuse treatment . Interview with resident #1 on March 6, 2014, at 8:45 a.m., in the resident's room, confirmed a few weeks past, the resident took medication against their wishes. Continued interview confirmed the resident believed the nurse used poor judgment, in insisting the resident take the medication. Continued interview revealed the resident stated was not feeling well at the time and believed some of the medication was causing the problem. Interview on March 6, 2014, at 11:05 a.m., via telephone, with the Licensed Physical Therapy Assistant (LPTA) who was present when the nurse attempted to give resident #1 medication, confirmed the nurse had insisted the resident take the medication, even though the resident had declined. Inte… | 2017-03-01 |
| 9464 | 9464 | MILAN HEALTH CARE CENTER | 445349 | 8060 STINSON ROAD | MILAN | TN | 38358 | 2015-08-21 | 155 | F | 0 | 1 | NSR011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's list of staff certified in Cardiopulmonary Resuscitation (CPR), record review and interview, the facility failed to ensure CPR certified staff were available on the 11 PM to 7 AM shifts for 12 of 30 days in [DATE] of 31 days in [DATE] and 12 of 31 days in [DATE]. The findings included: Review of the CPR Certified Staff by Shift list provided to the surveyor had one nurse listed under the 3rd Shift. Review of the list of the facility staff certified in CPR and the schedule revealed there was no one certified in CPR scheduled to cover the 11 PM to 7 AM shift for [DATE], 7, 8, 9, 10, 11 and 12, 2015, for [DATE], 5, 9, 12, 17, 18, 23, 24, 29 and 30, 2015 and for [DATE], 5, 6, 10, 11, 16, 17, 22, 23, 28 and 29, 2015. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 12:35 PM, in the dining room, the ADON was asked how many nurses work 11 PM to 7 AM. The ADON stated, The only nurses who work 11 to 7 are (named Licensed Practical Nurse (LPN) #2) (she) works split shifts, two 3 PM to 11 PM shifts, then works two 11 PM to 7 AM shifts. We only have one nurse on 11 to 7. Interview with the Director of Nursing (DON) on [DATE] at 2:34 PM, in the conference room, the DON was asked whether any CPR certified person was present when named LPN #1 was off. The DON stated, We don't right now, we just found that out yesterday. We are now working on that real hard and going to have a certified nurse here when (named LPN #1) is not. | 2016-12-01 |
| 9896 | 9896 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2013-09-20 | 155 | D | 1 | 0 | Y2MX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Resident's Rights, medical record review, review of a facility investigation, and interview, the facility failed to permit a resident to refuse treatment for one resident (#1) of eight sampled residents. The findings included: Review of the facility's Resident's Rights provided by the Director of Nursing (DON) on September 13, 2013, revealed, .Each resident has at least the following rights .To refuse treatment. The resident must be informed of the consequences of that decision. The refusal and its reason must be reported to the physician and documented in the resident's file . Medical record review revealed Resident #1 was readmitted to the facility on [DATE], and [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's cognition was intact and the resident required total assistance with bed mobility, transfers, dressing, and hygiene. Medical record review of a physician's orders [REDACTED].DC PO (discontinue oral) [MEDICATION NAME] - refuses to take. [MEDICATION NAME] 9.75 mg IM (milligrams intramuscular) for acute [MEDICAL CONDITION] repeat in 2 hrs prn (hours as needed) .Maximum 30 mg daily . Medical record review of a nurse's note dated February 14, 2013, at 4:00 p.m., revealed, .c/o (complained of) chest pain. Called (Medical Doctor - M.D. #1) and adv (advised) of complaints. (M.D. #1) .stated to give PRN dose of [MEDICATION NAME] IM. Adv (advised) had been refusing meds (medications) daily .' IM injection given in L (left) thigh. Medical record review of the next nurse's note dated February 14, 2013, at 6:30 p.m., revealed no documentation regarding refusal of the medication, informing the patient of the consequences of the decision to refuse, and/or notification of the physician of the patient's refusal prior to the injection. Continued review revealed, Follow-up from injection. Calm . Review of a witness statement (Director of Nursing's) in … | 2016-09-01 |
| 9955 | 9955 | PRINCETON TRANS CARE AT NORTH | 445356 | 400 NORTH STATE OF FRANKLIN ROAD | JOHNSON CITY | TN | 37601 | 2013-03-20 | 155 | D | 0 | 1 | 5KH511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a Physician order [REDACTED].#3, #5, #7) of eleven residents reviewed. The findings included: Resident # 3 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the medical record revealed the POST Form had not been completed. Interview with Registered Nurse (RN #1) on March 18, 2013, at 3:30 p.m., at the nursing station, confirmed the POST had not been completed. Resident # 7 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the medical record revealed the POST had not been completed. Interview with RN #1 on March 19, 2013, at 1:00 p.m., at the nursing station, confirmed the POST had not been completed. Resident # 5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the medical record revealed the POST had not been completed. Interview with the Director of Nursing at the nursing station on March 19, 2013, at 11:30 a.m., verified the POST had not been executed for resident #5. Interview continued and revealed the facility did not have a policy and procedure in place to ensure residents who transferred from a hospital without a POST had one executed. | 2016-09-01 |
| 10137 | 10137 | WESTMORELAND HEALTH AND REHABILITATION CENTER | 445114 | 5837 LYONS VIEW PIKE | KNOXVILLE | TN | 37919 | 2013-08-06 | 155 | D | 1 | 0 | MCPM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to assist three residents (#1, #3, #5) in securing an advance directive for end of life decisions of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a Physician order [REDACTED]. The POST document was executed on March 22, 2013, by a hospital Physician, five days prior to admission to the facility. The Physician's signature was not accompanied by the patient's and/or a surrogate's signature as required. Interview with the Director of Nursing on August 1, 2013, at 2:30 p.m., in the education room, confirmed the facility had failed to assist the resident during their thirty-eight day length of stay to secure a valid advanced directive. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a POST document placed in the front of the resident's medical record. Review of the POS [REDACTED]. The POST documented this as the patient's preference as discussed with the patient. The document was not signed by the patient/resident. The document was signed only by the resident's niece. The document did not contain the mandatory Physician and patient signatures for the DNR to be in effect. Interview with resident #3 on August 1, 2013, at 9:50 a.m., in their room, revealed an alert and oriented resident able to share pertinent details of their medical history, family dynamics, and goal to return home. Interview with the director of Nursing on August 5, 2013, at 3:30 p.m., in the education room, confirmed the facility had not assisted the resident in securing a valid advanced directive. Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with resident #5 on August 5, 2013, at 8:20 a.m., in their room, revealed an alert resident able to share details about breakfast, but not willing to talk abo… | 2016-07-01 |
| 10790 | 10790 | BLEDSOE COUNTY NURSING HOME | 4.4e+233 | 107 WHEELERTOWN AVENUE | PIKEVILLE | TN | 37367 | 2012-09-26 | 155 | D | 0 | 1 | L8M811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to respect the resident's right to refuse treatment for one resident (#38) of twenty-four residents reviewed. The findings included: Resident #38 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had no cognitive impairment and was totally dependent on staff for toileting and bathing. Medical record review of the Care Plan dated September 25, 2009, and updated quarterly revealed, .Resident is extensive to total dependent for all ADL's (Activities of Daily Living) .Verbally prompt resident to perform self-care and make choices as much as possible . Medical record review of the Licensed Nurses Notes dated July 10, 2012, revealed, .Was informed by CNAs that resident had refused to weighed (sp) for the month .After speaking (with) social services and care plan coordinator this charge nurse and another charge nurse informed resident that (resident) couldn't refuse to be weighed . Interview with the Director of Nursing (DON) on September 25, 2012, at 1:30 p.m., in the Chapel, confirmed the facility told the resident the resident could not refuse to be weighed and the facility had failed to respect the resident's right to refuse. | 2016-05-01 |
| 11753 | 11753 | NHC HEALTHCARE, SMITHVILLE | 445116 | 825 FISHER AVE P O BOX 549 | SMITHVILLE | TN | 37166 | 2011-12-06 | 155 | D | 0 | 1 | SU4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to honor a resident's right to refuse treatment for one resident (#5) of twenty-eight residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record view of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS-no cognitive impairment) and required extensive assistance with eating. Medical record review of a physician's orders [REDACTED]. Medical record review of a nurses' note dated November 29, 2011, revealed .patient complains X2 (times two) days of not receiving snacks patient reminded of diet order. Medical record review of a nurses' note dated December 1, 2011, revealed .pt (patient) argumented (argumentative) about diet et (and) MD (Medical Doctor) order of 1800 calorie diet. Pt still continues to request snacks after dinner. Medical record review of a dietary progress note dated December 1, 2011, revealed Resident continuing to voice complaints about current diet order of 1800 cal or less diet/ Observation and interview with the resident on December 4, 2011, at 12:25 p.m., and 3:01 p.m., and December 5, 2011, at 9:55 a.m., and 11:25 a.m., in the resident's room, revealed the resident's physician ordered a reduced calorie diet because the resident was fat and had a fatty liver. Further interview revealed the resident understood the ordered diet but did not want to be on the ordered diet. Further interview revealed the resident had told the physician, the director of nursing (DON), and the dietician the resident did not want to be on the ordered diet, but the facility refused the resident's requests for any foods or snacks not within the ordered diet. Interview with Registered Nurse (RN) #3 on December 5, 2011, at 9:06 a.m., outside the resident's room, confirmed staff were not providing any snacks the resident… | 2015-11-01 |
| 12691 | 12691 | WEST HILLS HEALTH AND REHAB | 445501 | 6801 MIDDLEBROOK PIKE | KNOXVILLE | TN | 37919 | 2012-05-18 | 155 | J | 1 | 0 | LG2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interviews, the facility failed to follow advance directives to provide emergency resuscitation for one resident (#1) of twenty residents reviewed. The facility's failure resulted in Cardio-Pulmonary Resuscitation (CPR) not being initiated for at least five minutes after the resident was found without respirations, CPR being unsuccessful, and the resident was pronounced (officially diagnosed and declared) dead at 8:05 p.m. on [DATE]. The facility's failure resulted in an Immediate Jeopardy. The Administrator, the Corporate Nurse, and the Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office, on [DATE], at 11:00 a.m. The findings included: Medical record review revealed Resident #1 was initially admitted to the facility on [DATE]. Review of a history and physical dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review of this history and physical revealed Resident #1 was a "full code" (has advance directives for resuscitation measures, if found without breath or pulse, which may include providing respirations, chest compressions, electrical shock, and medications). Review of Departmental Notes (computerized multi-disciplinary notes), dated [DATE], revealed the resident fell out of the bed, at approximately 11:50 p.m., and was transferred to the hospital. Further record review revealed the resident was readmitted to the facility on [DATE], following hospitalization for surgical repair of a left [MEDICAL CONDITION]. Review of the resident's Re-admission orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's Care Plan, dated [DATE], revealed, "Advance Directive...Full Code...Resuscitate". Review of facility Departmental Notes dated [DATE], at 7:35 p.m. revealed, "...resident did not have signs of respirations or was a pulse palpated..." Further review of the Departmental Notes revealed, "7:40 p.m. Code … | 2015-08-01 |
| 13154 | 13154 | BLEDSOE COUNTY NURSING HOME | 4.4e+233 | 107 WHEELERTOWN AVENUE | PIKEVILLE | TN | 37367 | 2011-03-24 | 155 | D | 0 | 1 | TG1H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain advanced directive information for one resident (#8) of fifteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was a DNR (Do Not Resuscitate) status. Medical record review of the MDS dated [DATE], revealed the resident's Brief Interview for Mental Status (cognitive status) was one out of fifteen (fifteen being highest cognitive status). Medical record review of the Social Services notes from admission to the present revealed no documentation of addressing advanced directive information with a responsible party. Medical record review of the Patient Care Plan review dated [DATE], [DATE], [DATE], and [DATE], revealed the resident's "...Code status: DNR...or NO CPR..." Interview, with the Social Worker on [DATE], at 9:50 a.m. and 3:15 p.m., in the Social Worker's office, confirmed the social worker failed to obtain the Physician order [REDACTED]. Further interview confirmed the social worker failed to periodically check the advanced directive status of the resident. Further interview revealed the responsible party was contacted and confirmed the DNR status was appropriate. | 2015-05-01 |
| 1447 | 1447 | AHC CUMBERLAND | 445262 | 4343 ASHLAND CITY HIGHWAY | NASHVILLE | TN | 37218 | 2017-03-09 | 156 | E | 0 | 1 | 955Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview the facility failed to provide appropriate Advanced Beneficiary Notices (ABN) for 3 of 3 (#14, 29, and 40) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility was unable to provide an advanced beneficiary notice for Resident #14, 29 and 40. Interview with the Administrator on 3/8/17 at 11:30 AM, in the Administrator's office, the Administrator was asked about the ABNs that were requested for Resident #14, 29, and 40. The Administrator stated .what happened the Business office coordinator started on [DATE]th (2016) and she wasn't aware she was supposed to be doing the ABN's. She was told later . The Administrator was asked if he expected the ABN's to be completed. The Administrator stated, Yes, absolutely . | 2020-09-01 |
| 1585 | 1585 | CAMDEN HEALTHCARE & REHAB CENTER | 445274 | 197 HOSPITAL DRIVE | CAMDEN | TN | 38320 | 2017-09-27 | 156 | D | 0 | 1 | EUZQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to provide appropriate liability and appeal notices for 2 of 3 (Resident #10 and 11) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's Resident Beneficiary Notice(s) policy documented, .Skilled Nursing Facility (SNF) .required to provide a NOMNC (Notice of Medicare Non-Coverage) to beneficiaries when their Medicare covered service(s) are ending . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10's NOMNC documented, .The Effective Date Coverage of Your Current: Skilled Nursing Services Will End .May 11, (YEAR) . There was no documentation that Resident #10 or the family acknowledged that they had been notified prior to the end of the coverage date of 5/11/17. 3. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's NOMNC documented, .The Effective Date Coverage of Your Current: Skilled Nursing Services Will End .May 14, (YEAR) . There was no documentation that Resident #11 or the family acknowledged that they had been notified prior to the end of the coverage date of 5/14/17. 4. Interview with the Minimum Data Set (MDS) Coordinator on 9/26/17 at 10:05 AM, in the conference room, the MDS Coordinator was asked if certified letters had been sent related to Resident #10 and 11's Medicare covered services ending. The MDS Coordinator confirmed that no one had signed the notifications and no certified letters had been sent. | 2020-09-01 |
| 2736 | 2736 | MISSION CONVALESCENT HOME | 445447 | 118 GLASS ST | JACKSON | TN | 38301 | 2017-11-21 | 156 | C | 0 | 1 | CXGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #16, 28, and 44) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's Form Instructions for the Notice of Medicare Non-Coverage . policy documented, .A Medicare provider .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing .services .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service of care is not being provided daily .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .The effective date coverage of your current Medicare Part A Service will end: 7-19-17 . There was no signature of the resident or resident representative indicating advance notice was provided. The Discharge Summary documented a discharge date of [DATE]. 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The NOTICE OF MEDICARE NON-COVERAGE form documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT .Skilled Rehab (Rehabilitation) .SERVICES WILL END: 9-15-17 . There was no signature of the resident or resident representative indicating advance notice was provided. Resident #28 was still residing at the facility, 4. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .T… | 2020-09-01 |
| 2920 | 2920 | HENDERSON HEALTH AND REHABILITATION CENTER | 445471 | 412 JUANITA DRIVE | HENDERSON | TN | 38340 | 2017-06-22 | 156 | D | 0 | 1 | PPF211 | Based on Advance Beneficiary Notice of Noncoverage (ABN) form review and interview, the facility failed to provide the appropriate liability and appeal notice for 1 of 3 (Resident #16) sampled residents reviewed for liability and appeal notices. The finding included: The ABN form for Resident #16 documented, The Effective Date Coverage of Your Current Skilled Rehab (rehabilitation) Services Will End: (MONTH) 10, (YEAR) .have been notified that coverage of my services will end on the effective date indicated on this notice .Signature of Patient or Representative .verbal by phone .Date .5/10/17 . Interview with the Administrator on 6/22/17 at 10:53 AM, in the Administrator's office, the Administrator was asked for a policy regarding ABN's. The Administrator stated, We do not have a policy .it's a 3 day notification . Interview with the Assistant Social Services Director on 6/22/17 at 11:00 AM, in the Administrator's office, the Assistant Social Services Director stated, .had attempted to call (Resident #16's) grandson 3 days prior to services ending, with no answer .I did not document the attempt to notify . | 2020-09-01 |
| 3640 | 3640 | PALMYRA HEALTH AND REHABILITATION | 445184 | 2727 PALMYRA RD | PALMYRA | TN | 37142 | 2017-05-25 | 156 | C | 0 | 1 | K3HH11 | Based on medical record review and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #8,17 and 28) sampled residents reviewed for liability and appeal notices. The findings included: Medical record review revealed Resident #8 had a therapy end date of 5/7/17 with a documented telephone notification on 5/4/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #8's responsible party (RP). Medical record review revealed Resident #17 had a therapy end date of 2/10/17 with a documented telephone notification on 2/5/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #17's responsible party. Medical record review revealed Resident #28 had a therapy end date of 3/13/17 with a documented telephone notification on 3/7/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #28's responsible party. Interview with the Business Office Manager on 5/23/17 at 4:26 PM, in the conference room, the Business Office Manager stated, I failed to tell you that we did not send letters to those family members. The Business Office Manager was asked if she could provide any proof that the letters were sent. The Business Office Manager stated, No ma'am they were never sent. Interview with the Administrator on 5/23/27 at 4:45 PM, in the conference room, the Administrator stated, .no letters were mailed out . Interview with the Social Services Director on 5/23/17 at 5:48 PM, in the Administrator's office, the Social Services Director was asked if Resident #28 was his own patient representative because his notification letter stated he refused to sign. The Social Services Director stated, No his ex-wife is his RP. The Social Services Director was asked if Resident #28's RP should have been the person receiving the liability appeal letter. The Social Services Director stated, Yes. | 2020-04-01 |
| 3673 | 3673 | GREEN HILLS CENTER FOR REHABILITATION AND HEALING | 445267 | 3939 HILLSBORO CIRCLE | NASHVILLE | TN | 37215 | 2016-11-09 | 156 | D | 0 | 1 | 65VV11 | Based on policy review, medical record review and interview the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Resident # 144 and 149) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's Medicare Letters of Non-Coverage policy documented, Medicare letters of non-coverage are used to notify the resident of Medicare non-coverage at the time of admission, or of termination of benefits prior to discontinuation of either covered Medicare Part A stay or Medicare Part B Therapies .Notice Requirements .All remaining notices are delivered to the resident or responsible party a minimum of two (2) days prior to the last covered day .If unable to personally deliver the CMS required forms to the Resident or Responsible Party, Social Services (or Rehab Program Manger) must telephone the Responsible Party to notify them of the last covered day and the expedited review process .The call must be documented on all notices .Information must include name of caller, person contacted, date and time of call and telephone number All notices must be mailed to the Responsible Party the same day of the call. Please include two copies, one for their records and one to sign and return .If unable to reach the Responsible Party by telephone, the notices must be sent via certified mail, return receipt requested .Copies of all signed notices are maintained in the resident's financial file . 2. The .Notice of Medicare Non-Coverage form for Resident #144 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 6/20/16 . A handwritten note on the bottom of the notice documented, 6/17/16 - Tried to contact (named Resident #144's responsible party), daughter .Call was unanswered . 3. The .Notice of Medicare Non-Coverage form for Resident #149 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: Nov. 8, (YEAR) . A handwritten note on the bottom of the notice documented, .11/7/16 .Contacted (name… | 2020-04-01 |
| 3930 | 3930 | COUNTRYSIDE HEALTHCARE AND REHABILITATION | 445280 | 3051 BUFFALO ROAD | LAWRENCEBURG | TN | 38464 | 2017-02-08 | 156 | D | 0 | 1 | 2N4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to provide appropriate liability and appeal notices for 2 of 3 (Resident #25 and 97) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's SNF (Skilled Nursing Facility) - Beneficiary Notice Requirements documented, .Situation .Part A Stay will end because: Provider determines that beneficiary no longer requires daily, skilled services .Beneficiary will not be receiving therapy or other part B services, resident will remain in facility (custodial) .Part A Stay will end because: Provider determines that beneficiary no longer requires daily skilled services, resident will be discharged home .Expedited Determination Notice(s) .CMS (Centers for Medicare/Medicaid) & (and) Part A & B .Part A Stay ends because: Resident has exhausted 100 days of SNF Part A coverage. (Technical Denial) .SNF NEMB (Notice of Exclusions from Medicare Benefits) or other type of notice (Voluntary) . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The A/R (Accounts Receivable) Type History for Resident #25 documented .Date of Change .10/03/2016 .A/R Type .MRA (Medicare) .Date of Change .10/19/2016 .A/R Type .MDN (Medicaid) . Interview with the Social Worker (SW) on 2/8/17 at 11:00 AM, in room [ROOM NUMBER], the SW was asked whether there was documentation that Resident #25 received advanced notice for the ending of covered Medicare services. The SW stated, His wife has a mental illness, so there was no way to have her sign. The SW was asked whether the resident was capable to sign. The SW stated, No. The SW was asked who was Resident #25's Responsible Party. The SW stated, .He did not sign a cut letter, no. 3. Medical record review revealed Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #97's Notice of Medicare Non-Coverage documented, .The E… | 2020-01-01 |
| 4175 | 4175 | LEWIS COUNTY NURSING AND REHABILITATION CENTER | 445430 | 119 KITTRELL ST, PO BOX 129 | HOHENWALD | TN | 38462 | 2017-01-19 | 156 | C | 0 | 1 | ZHG411 | Based on record review and interview, the facility failed to provide the appropriate liability and appeal for 1 of 4 (Resident #74) sampled residents reviewed for liability and appeal notices. The findings included: Review of the advanced beneficiary notices on 1/20/17 at 6:40 PM, in the Admissions Office, the facility was unable to provide an advanced beneficiary notice for Resident #74. Interview with the Social Services Director (SSD), on 1/18/17 at 6:48 PM, in the Admissions Office, the SSD stated, .I couldn't find the letter (advanced beneficiary letter) for (Named resident) .I think she went long term care .I dropped the ball on it .she had additional days left . | 2019-11-01 |
| 4653 | 4653 | WHITEHAVEN COMMUNITY LIVING CENTER | 445233 | 1076 CHAMBLISS ROAD | MEMPHIS | TN | 38116 | 2016-06-28 | 156 | D | 0 | 1 | N42U11 | Based on review of a Survey and Certification Letter, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 1 of 2 (Residents #64) sampled residents reviewed for liability and appeal notices. The findings included: The Survey and Certification Letter Ref (reference): S&C (Survey and Certification) - 09-20 dated 1/9/09 documented, .Notice Delivery to Representatives . Providers are required to develop procedures to use when the beneficiary is incapable . and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact . provider should telephone the representative . Confirm telephone contact by written notice mailed on that same date . The .Notice of Medicare Non-Coverage form for Resident #64 documented, .The Effective Date Coverage of Your Current OT (Occupational Therapy) Services Will End: 5/17/16 . Interview with the Business Office Manager (BOM) on 6/16/16 at 4:45 PM in the conference room, the BOM confirmed that she did not have documentation that the responsible party was notified in writing of the end of coverage. | 2019-08-01 |
| 4902 | 4902 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2016-06-09 | 156 | D | 0 | 1 | C1XT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage forms, resident council meeting minutes, medical record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #26 and 121) sampled residents reviewed for liability and appeal notices, and the facility failed to inform residents of ombudsman information during resident council meetings. The findings included: 1. The Notice of Medicare Non-Coverage form for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 3/9/2016 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 2. The Notice of Medicare Non-Coverage form for Resident #31 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 05/16/16 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 3. In an interview with the Social Worker (SW) on 6/9/16 at 11:10 AM, in the conference room, the SW was shown Resident #26 and 121's liability and appeal notices and the SW confirmed they had not been signed. The SW was asked how would she show that the residents had been informed. The SW stated, .I wouldn't . 4. Review of the monthly resident council meeting minutes dated (MONTH) through May, (YEAR) did not reflect any discussion of ombudsman information, where the information was posted or who the ombudsman was. 5. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. In an interview with Resident #121 on 6/9/16 at 9:18 AM, in Resident #121's room, she was asked are you familiar with where the ombudsman information is posted. Resident #121 stated, No ma'am. Resident #121 was asked are you familiar with the ombudsman? Re… | 2019-06-01 |
| 4914 | 4914 | NHC HEALTHCARE, SOMERVILLE | 445119 | 308 LAKE DRIVE, PO BOX 550 | SOMERVILLE | TN | 38068 | 2016-04-20 | 156 | C | 0 | 1 | 750M11 | Based on review of a Survey and Certification Letter, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #15, 59 and 87) sampled residents reviewed for liability and appeal notices. The findings included: 1. The Survey and Certification Letter Ref (reference): S&C (Survey and Certification) - 09-20 dated 1/9/09 documented, .Notice Delivery to Representatives . Providers are required to develop procedures to use when the beneficiary is incapable . and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact . provider should telephone the representative . Confirm telephone contact by written notice mailed on that same date . 2. The Notice of Medicare Non-Coverage form for Resident #15 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & (and) Therapy) Services Will End: 1/19/16 . Telephone contact was made with the resident's responsible party on 1/14/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 3. The Notice of Medicare Non-Coverage form for Resident #59 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 11/6/2015 . Telephone contact was made with the resident's responsible party on 11/2/15. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 4. The Notice of Medicare Non-Coverage form for Resident #87 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 3/09/2016 . Telephone contact was made with the resident's responsible party on 3/4/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 5. Interview with the Social Worker (SW) on 4/20/16 at 11:00 AM, in the Social Worker's office, the SW was asked if the date on the top of the page wa… | 2019-06-01 |
| 5281 | 5281 | LAUDERDALE COMMUNITY LIVING CENTER | 445354 | 215 LACKEY LANE | RIPLEY | TN | 38063 | 2017-05-05 | 156 | D | 0 | 1 | QMFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Advance Beneficiary Notice of Noncoverage (ABN) form review and interview the facility failed to provide the appropriate liability and appeal notice for 2 of 3 (Residents #2 and #6) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility did not have a policy regarding Advanced Beneficiary Notices (ABN) but provided a typed statement that documented, Lauderdale Community Living Center uses the guidelines set forth by Centers for Medicare & Medicaid Services for the completion of Advanced Beneficiary Notices. The facility supplied the survey team with a copy of Medicare Advance Beneficiary Notices from the .Centers for Medicare & (and) Medicaid Services which documented, .The ABN allows the beneficiary to make an informed decision about whether to get the item or service that may not be covered and accept financial responsibility if Medicare does not pay. If the beneficiary does not get written notice when it is required, he or she may not be held financially liable if Medicare denies payment, and you may be financially liable if Medicare does not pay . 2. The ABN form for Resident #2 did not document a date that skilled services would end. The form was signed by the resident's representative on [DATE]. 3. The ABN form for Resident #6 did not document a date that skilled services would end. The form was signed by the resident's representative on [DATE]. 4. Interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 9:05 AM, in the Conference Room, the MDS Coordinator was shown the ABN forms for Residents #2 and #6 and was asked what day their coverage expired and if that date should be on the form that the resident or resident's representative signed. The MDS Coordinator stated, Absolutely .learned that yesterday .there was a form I didn't have .I know they have three days to appeal .I did learn that yesterday . The MDS Coordinator was unable to identify the date the coverage expired … | 2019-04-01 |
| 5474 | 5474 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2015-08-27 | 156 | E | 0 | 1 | 66JE11 | Based on record review and interview, the facility failed to provide a Notice of Medicare Non - Coverage for 1 of 3 (Resident #89) sampled resident and failed to provide completed information of a Notice of Medicate Non - Coverage for 2 of 3 (Residents #99 and #113) sampled residents reviewed for Notice of Medicare Non-Coverage. The findings included: 1. Resident #89 received Medicare A services from 5/11/15 to 6/5/15. The facility could not provide a Notice of Medicare Non-Coverage, a form that provides the information that the resident has the right to request a review of the Medicare A services the resident received from the Quality Improvement Organization (QIO). Interview with Administrative staff E on 8/27/15 at 12:17 PM, revealed the facility lacked evidence of a Notice of Medicare Non-Coverage for this resident. 2. Resident #99's Notice of Medicare Non - Coverage revealed the resident's Skilled Services would end on 5/19/15. The notice lacked the QIO's address and phone number. Interview with Administrative Staff E on 8/27/15 at 12:17 PM, confirmed the notice did not include the phone number or address of the QIO. 3. Resident #113's Notice of Medicare Non - Coverage revealed the resident's Skilled Services would end on 6/4/15. The notice lacked the QIO's address and phone number. Interview with Administrative Staff E on 827/15 at 12:17 PM, confirmed the notice did not include the phone number or address of the QIO. The facility failed to provide a Notice of Medicare Non-Coverage or a complete Notice of Medicare Non-Coverage. | 2019-02-01 |
| 5529 | 5529 | CLARKSVILLE MANOR NURSING CENTER | 445455 | 900 PROFESSIONAL PARK DRIVE | CLARKSVILLE | TN | 37040 | 2015-11-05 | 156 | E | 0 | 1 | 4Z6811 | Based on policy review, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #31, 41 and 51) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's OTHER CMS (Centers for Medicare and Medicaid Services) REQUIREMENTS . policy documented, .Determination of Coverage (Cut Letters) . The patient and/or patient's responsible party must be notified in writing regarding the discharge from Part A and Part B services. The Determination of Coverage on Extended Stay (Cut Letters) and the Expedited Review, Generic Notice (CMS Form ) must be issued 3 days prior to patient discharge. The patient/family signature and date on this form should be a minimum of 3 business days prior to the discharge of services . 2. The Notice of Medicare Non-Coverage form for Resident #31 documented, .The Effective Date Coverage of Your Current Skilled Care Services Will End: 8-19-15 . The resident's responsible party signed and dated the form on 8/17/15. 3. The Notice of Medicare Non-Coverage form for Resident #41 documented, .The Effective Date Coverage of Your Current Skilled Care Services Will End: 6/25/15 . Telephone contact was made with the resident's responsible party on 6/17/15. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice. 4. The Notice of Medicare Non-Coverage form for Resident #51 documented, .The Effective Date Coverage of Your Current Skilled Care Services Will End: 9/18/2015 . The patient signed the form on 9/17/15. The facility was not able to provide any documentation that any earlier notice was given. 5. Interview with the Social Services' Director (SSD) on 11/3/15 at 5:45 PM, in the SSD's office, the SSD was asked how much notice should be provided to residents before the end of coverage. The SSD stated, At least the 3 days, and most of the time we normally do even more. The SSD was asked whether a written notice was provided for Resident #41. The… | 2019-02-01 |
| 5678 | 5678 | LAURELWOOD HEALTHCARE CENTER | 445413 | 200 BIRCH ST | JACKSON | TN | 38301 | 2015-08-12 | 156 | B | 0 | 1 | Z3X911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #46 and 64) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #46 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 06.08.15 and on 06.09.15 . The form was signed but not dated by the Patient / Representative. Interview with the Social Worker on 3/12/15 at 2:30 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #46 was not dated by the Patient/Representative. 2. Review of the Notice of Medicare Non-Coverage for Resident #64 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 07.7.15 . The Patient/Representative signed and dated the form on 7/14/15. Interview with the Social Worker on 3/12/15 at 2:35 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #64 was not signed and dated by the Patient / Representative prior to the effective date of non-coverage. | 2019-01-01 |
| 5820 | 5820 | WAVERLY HEALTH CARE & REHABILITATION CENTER | 445251 | 895 POWERS BLVD | WAVERLY | TN | 37185 | 2015-08-06 | 156 | E | 0 | 1 | 9MOG11 | Based on record review and interview, the facility failed to provide a Notice of Medicare Non - Coverage for 2 of 3 (Residents #26 and #12) residents of the sample reviewed for liability notices. The findings included: 1. Resident #26 received skilled services from 4/7/15 to 4/21/15. Interview with Administrative Staff J on 7/30/15 at 11:58 A.M. revealed the facility could not find the Notice of Medicare Non-Coverage for this resident. The facility lacked documentation that they provided the Notice of Medicare Non-Coverage for this resident. 2. Resident #12 received skilled services from 2/24/15 to 5/26/15. Interview with Administrative Staff J on 7/30/15 at 11:58 A.M. revealed the facility could not find the Notice of Medicare Non-Coverage for this resident. The facility lacked documentation that they provided the Notice of Medicare Non-Coverage for this resident. | 2018-11-01 |
| 5967 | 5967 | MAJESTIC GARDENS AT MEMPHIS REHAB & SNC | 445150 | 131 N TUCKER | MEMPHIS | TN | 38104 | 2015-05-08 | 156 | E | 0 | 1 | 2SUG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #143 and 169) sampled residents. The findings included: 1. Medical record review revealed Resident #143 was admitted to the facility on [DATE] for skilled services. The Discharge Orders dated 1/12/15 documented, .Discharge patient to the care of family/friends when all arrangements are complete . The facility was unable to provide in writing where the resident or the representative was given an Advanced Beneficiary Notice or Liability Notice (ABN) prior to discharge as required by law. 2. Medical record review revealed Resident #169 was admitted to the facility on [DATE] for skilled services. The Discharge Orders dated 1/30/15 documented, .Discharge patient to the care of family/friends when all arrangements are complete . The facility was unable to provide in writing where the resident or the representative was given an Advanced Beneficiary Notice or Liability Notice (ABN) prior to discharge as required by law. 3. Interview with the Social Worker (SW) on 5/7/15 at 3:15 PM, in the family room, the SW stated, Can not find where a notice was sent to them (Resident #143 and #169), only been doing this position for 2 weeks. I can not find where the previous Social Worker has any of them. I am keeping them in a book now. I have looked and can only find ones on the residents who exhausted their days (which would not even require an ABN). | 2018-10-01 |
| 6064 | 6064 | PICKETT CARE AND REHABILITATION CENTER | 445390 | 129 HILLCREST DRIVE | BYRDSTOWN | TN | 38549 | 2015-07-08 | 156 | D | 0 | 1 | L07311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide timely notification of non-covered skilled services for 1 resident (#70) of 3 residents reviewed. The findings included: Medical record review revealed Resident #70 was admitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of admission orders [REDACTED].rehab potential: Good . Review of a Physician's progress note dated 2/26/15, revealed Resident #70 required assistance with activities of daily living, medication administration, skilled nursing, and physical therapy. Medical record review of the Physical Therapy Discharge Summary dated 3/6/15, revealed Resident #70 had reached maximum potential with skilled services. Medical record review of the Occupational Therapy Discharge Summary dated 3/6/15, revealed Resident #70 had achieved the highest practical level of functioning. Review of the Notice of Medicare Non-Coverage letter provided to the resident by the facility revealed the resident's skilled nursing services would end on 3/6/15. Continued review of the letter revealed the resident had acknowledged the letter on 3/11/15, five days after services ended. Interview with the Administrator on 7/7/15, at 4:58 PM, in the conference room, confirmed the resident had 46 skilled days available at the time skilled services were discontinued. Continued interview confirmed the notification of non-coverage had not been provided to the resident prior to the date the services would end. | 2018-10-01 |
| 6081 | 6081 | SIGNATURE HEALTHCARE OF CLARKSVILLE | 445448 | 198 OLD FARMER ROAD | CLARKSVILLE | TN | 37043 | 2015-07-09 | 156 | E | 0 | 1 | 9R4511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, 3 of 4 (Residents #25, #56 and #160) residents selected for a review of liability notice in stage 2 were not given the appropriate liability and appeal notice at the time of discharge. The findings included: 1. Resident #25 was admitted on [DATE] for rehabilitation services. [DIAGNOSES REDACTED]. Physical therapy was started on 4/1/15 and a discharge note was written on 4/29/15. The resident was discharged to home due to exhausted benefits, patient/ representative (RSP) declines treatment. Physician order [REDACTED]. Discharge summary completed on 4/30/15 note for PT, OT, and ST revealed the patient participated in PT, OT, ST services with discharge home related to refusal to pay copay. No evidence that the appropriate liability notice was issued on or after 4/28/15 when doctor's order was written for discharge. 2. Resident #56 was admitted on [DATE] for rehabilitation services. [DIAGNOSES REDACTED]. The last daily skilled nurse's note, dated 3/3/15, noted the resident was alert, oriented and able to verbalize needs. This resident was able to transfer to wheelchair and to toilet with little assistance. The resident required moderate assist with Activities of Daily Living (ADLs) and had no complaints of pain at this time. Resident #56 was able to take medications without difficulty. This resident was observed to be resting comfortably with call light within reach. There was no indication of resident's decision to be discharged [DATE]. Social Services progress note of 3/3/2015 noted the resident requested discharge on 3/4/15. Occupational Therapy noted service dates between 2/20/15 through 3/3/15 with a discharge note stating resident was being discharged to home per physician or case manager. The discharge was resident's choice. A physician order [REDACTED]. 3. Resident #160 discharged from PT on 5/18/15 and OT on 5/19/15, and was present in the facility until 5/26/15. Interview on 7/9/15 at 2:52 P.M., Bus… | 2018-10-01 |
| 6214 | 6214 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2015-06-11 | 156 | D | 0 | 1 | 9ZLX11 | Based on record review, interview and review of the Centers for Medicare and Medicaid Services (CMS) form titled Form Instruction for the Notice of Medicare Non-Coverage (NOMNC) CMS- , the facility failed to provide a notification of discontinued Medicare services for 1 of 3 (Resident #5) residents sampled for notification of Medicare Non-Coverage notification. The findings included: Review of 3 resident's Notice of Medicare Non-Coverage revealed Resident #5 lacked a notification letter including the date of discontinued services, the appeal process and contact information to appeal the decision, and the signature of the resident (beneficiary). Interview on 6/11/15 at 2:17 PM, the Social Services Director (SSD) stated Resident #5 was discharged from Medicare skilled services on 6/10/15. The SSD did not give the resident a notice of discharge and rights of appeal information because he/she thought a notice was not required for a resident on managed care services. He/She gave the notices to other residents, but did not give this resident a notice. Licensed Nurse #6 provided the CMS form on 6/11/15 at 4:14 PM, titled Form Instruction for the Notice of Medicare Non-Coverage (NOMNC) CMS- . Licensed Nurse #6 stated the document was followed by the facility, but was not a policy. The Form Instructions for the Notice of Medicare Non-Coverage - CMS - directed: A Medicare provider or health plan . must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries / enrollees receiving covered skilled nursing . services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily . The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . The facility failed to provide a Medicare Non-Coverage notification to Resident #5. | 2018-09-01 |
| 6531 | 6531 | SIGNATURE HEALTHCARE OF ERIN | 445377 | 278 ROCKY HOLLOW ROAD | ERIN | TN | 37061 | 2015-03-19 | 156 | E | 0 | 1 | FS4W11 | Based on policy review, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #36 and 97) sampled residents. The finding included: 1. Review of the facility's Notice of Medicare Non-Coverage (NOMC) policy documented, .NOMNCs will be delivered to all Medicare beneficiaries at least forty-eight (48) hours or two (2) days prior to anticipated termination of services . 2. Review of the Notice of Medicare Non-Coverage for Resident #36 documented, .The Effective Date Coverage of Your Current . Part A Services Will End JANUARY 23, (YEAR) . Record review revealed a telephone contact with the representative was made on 1/15/15. There is no documentation the telephone contact was confirmed by written notice on that same day. 3. Review of the Notice of Medicare Non-Coverage for Resident #97 documented, .The Effective Date Coverage of Your Current . Skilled Nursing Services Will End: 01/24/2015 . Record review, revealed a telephone contact with the representative was made on 1/13/15. There is no documentation the telephone contact was confirmed by written notice on that same day. 4. Interview with the Business Manager on 3/18/15 at 10:55 AM, in the business office, the Business Manager was asked if the date on the top of the page was the date she notified the resident or power of attorney of the end of their services for Resident #36 and 97. The Business Manager stated, Yes, I mailed them in advance. The business Manager was then asked did she have any documentation that the letters were mailed on the date of notice. The Business Manager stated, No. | 2018-07-01 |
| 6648 | 6648 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 156 | E | 0 | 1 | XIH911 | Based on review of notices of medicare non-coverage forms and interview, the facility failed to provide the appropriate liability and appeal notices to 2 of 3 (Resident #71 and 134) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage form for Resident #71 documented a termination date of 9/5/14 and was signed by Resident #71's Responsible Party (RP) on 8/25/14. 2. Review of the Notice of Medicare Non-Coverage form for Resident #134 documented a termination date of 10/10/14 and was signed by Resident #134's RP on 8/26/14. 3. Interview with the admission's coordinator on 2/5/15 at 3:00 PM, outside the business office, the admission's coordinator was asked when she gets the Notice of Medicare non-Coverage form signed. The admission's coordinator stated, Sometimes I get them to sign them on admission because there are some families that don't come back for any of the care plan meetings. Sometimes I get them signed at the discharge planning meetings . it just depends on the family and the situation . that's why some of them are signed way in advance . I don't want to not ever have this signed . Interview with the admission's coordinator on 2/5/15 at 3:25 PM, in the 400 hallway, the admission's coordinator was asked if she would change the termination date on the Notice of Medicare non-Coverage if the resident's termination date changed. The admission's coordinator stated, No, I don't put the date on it until the discharge planning meeting is completed. The admission's coordinator was then asked if she had the responsible party sign the Notice of Medicare non-Coverage without having a termination date on it. The admission's coordinator stated, Yes. | 2018-05-01 |
| 6719 | 6719 | CUMBERLAND HEALTH CARE AND REHABILITATION INC | 445262 | 4343 ASHLAND CITY HWY | NASHVILLE | TN | 37218 | 2014-10-09 | 156 | C | 0 | 1 | ZBLF11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #26, #66 and 115) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 05-26-2014 . Telephone contact with the representative was made on 5/22/14. There is no documentation the telephone contact was confirmed by written notice on that same date. 2. Review of the Notice of Medicare Non-Coverage for Resident #66 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 08-14-14 . There is documentation with Resident #66's signature dated 8/18/14, four days after notification of Medicare Non-Coverage days. 3. Review of the Notice of Medicare Non-Coverage for Resident #115 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 06-06-2014 . Telephone contact with the representative was made on 5/22/14. There was no documentation the telephone contact was confirmed by written notice on that same date. 4. During an interview in the hallway on 10/8/14 at 6:30 PM, the Social Worker was asked to provide documentation where the Responsible Party had been notified in writing of the resident's Notice of Medicare Non-Coverage letter. The Social Worker stated, No, I do not have proof that I gave them a copy of the letter. The Social Worker was asked to verify the dates on Resident #66 Notice of Medicare Non-Coverage letter. The Social Worker stated, Oh, I can't believe I did that . I have the dates backward. | 2018-05-01 |
| 6949 | 6949 | WOODCREST AT BLAKEFORD | 445378 | 11 BURTON HILLS BLVD | NASHVILLE | TN | 37215 | 2014-09-10 | 156 | D | 0 | 1 | O65F11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice to 1 of 3 (Residents #131) sampled residents. The findings included: Review of the Notice of Medicare Non-Coverage for Resident #131 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: Thursday July 3, 2014 . Resident and dtr (daughter) verbally informed of d/c (discharge) date of 6/28/14 . There is no signature of the resident or the representative on the form. The facility was unable to provide in writing where the resident or the representative was given this information. During an interview in the Social Worker's office on 9/10/14 at 1:39 PM, the Social Worker (SW) was asked why there was no signature on Resident #131's Notice of Medicare Non-Coverage form. The SW stated, I just documented we had discussed it in the note. The SW was asked if she sent a copy of the Notice of Medicare Non-Coverage form for Resident #131 or the Representative to sign. The SW stated, No. | 2018-04-01 |
| 7103 | 7103 | THE KINGS DAUGHTERS AND SONS | 445221 | 3568 APPLING ROAD | BARTLETT | TN | 38133 | 2014-09-04 | 156 | E | 0 | 1 | QM2L11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #94 and 126) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #94 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 04-03-2014 . Telephone contact with the representative was made on 3/3/14. There is no documentation the telephone contact was confirmed by written notice on that same date. 2. Review of the Notice of Medicare Non-Coverage for Resident #126 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 04-06-14 . Telephone contact with the representative was made on 4/3/14. There is no documentation the telephone contact was confirmed by written notice on that same date. 3. During an interview in the Admission's office on 9/4/14 at 2:24 PM, the Admissions Coordinator was asked if she had mailed the notices to the responsible parties. The Admission's Coordinator stated, We always just call on the phone if the family doesn't visit or the resident can't sign. I didn't know they had to be made in writing. | 2018-03-01 |
| 7223 | 7223 | THE HIGHLANDS OF DYERSBURG HEALTH & REHAB | 445497 | 350 EAST TICKLE STREET | DYERSBURG | TN | 38024 | 2014-10-01 | 156 | D | 0 | 1 | FT1O11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice for 1 of 3 (Resident #43) sampled residents. The findings included: Review of the Notice of Medicare Non-Coverage for Resident #43 documented, .The Effective Date Coverage of Your Current Services Will End: 4-16-14 DC'd (discharged ) home . There is no signature of the resident or the representative on the form. The facility was unable to provide in writing where the resident or the representative was given this information. During an Interview in the conference room on 9/30/14 at 5:25 PM, the Minimum Data Set (MDS) Coordinator #2 was asked why there was no signature on Resident #43's Notice of Medicare Non-Coverage form. The MDS Coordinator #2 stated, I mailed out the notice to Resident #43, but that was before certified mail was used. I never got anything back from them. There is no proof other than my word. | 2018-03-01 |
| 7330 | 7330 | SIGNATURE HEALTHCARE OF CLEVELAND | 445369 | 2750 EXECUTIVE PARK PLACE | CLEVELAND | TN | 37312 | 2014-12-03 | 156 | D | 0 | 1 | F7K511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to issue a Notice of Medicare Provider Non Coverage for two (#131 and #87) of three residents reviewed for liability notices. The findings included: Resident #131 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Summary dated July 16, 2014, revealed the resident was discharged home with family and home health on July 4, 2014. Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Summary dated August 8, 2014, revealed the resident was discharged home with family on July 15, 2014. Interview on December 3, 2014, at 1:15 p.m., with the Administrator in the Administrator's office, revealed resident #131 and resident #87 were not issued letters of Notice of Medicare Provider Non Coverage,they were missed. Continued interview confirmed the residents were discharged home and had not given the opportunity to appeal the decision, as the the letters had not been issued. | 2018-02-01 |
| 7696 | 7696 | APPLINGWOOD HEALTH CARE CENTER | 445411 | 1536 APPLING CARE LANE | CORDOVA | TN | 38018 | 2014-05-15 | 156 | E | 0 | 1 | YI7411 | Based on record review and interview, it was determined the facility failed to provide 2 of 3 (Residents #28 and 128) sampled residents with the proper advanced beneficiary notices as required by law. The findings included: 1. Review of advanced beneficiary notices for Resident #28 revealed the effective date that the coverage would end was 1/10/14. Resident #28 was notifeid on 1/10/14, as documented on the dated signature of the power of attorney on the Notice of Medicare Non-Coverage form. 2. Review of advanced beneficiary notices for Resident #128 revealed the resident's end of coverage date was 12/24/13. Resident #128 signed the Notice of Medicare Non-Coverage form on 12/23/13. 3. During an interview in the administrator's office on 5/13/14 at 1:35 PM, the administrator was asked about the advanced beneficiary notices. The administrator stated, I'll be honest with you, the social worker we had before was not doing her part in some things. That's why she isn't here anymore. During an interview in the administrator's office on 5/14/14 at 4:50 PM, the administrator was asked how much notice is given before the end of coverage for services. The administrator stated, If we are exhausting their days, they are going to know roughly, (we) always do at least a 3-day notice. | 2017-11-01 |
| 7999 | 7999 | RIPLEY HEALTHCARE AND REHAB CENTER | 445492 | 118 HALLIBURTON DRIVE | RIPLEY | TN | 38063 | 2014-03-13 | 156 | D | 0 | 1 | K8WW11 | Based on review of Beneficiary Notices Initiative Summary- Part A, record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice for 2 of 3 (Residents #15 and 97) sampled residents The findings included: 1. Review of the Beneficiary Notices Initiative Summary - Part A documented, .SNF (Skilled Nursing Facility) . Yes - 2 days Before Termination of Services . 2. Review of the Notice of Medicare Non-Coverage for Resident #15 documented, .The Effective Date Coverage of Your Current Occupational therapy services . Services Will End 2/26/14 . Review of the therapy discharge letters documented the Advance Beneficiary Notice (ABN) letter was mailed on 2/27/14 after Resident #15 was discharged from skilled services. 3. Review of the Notice of Medicare Non-Coverage for Resident #97 documented, .The Effective Date Coverage of Your Current OT (Occupational Therapy), PT (Physical Therapy), and ST (Speech Therapy) services . Services Will End: 2/26/14 . Review of the therapy discharge letters documented the ABN letter was mailed on 2/27/14 after Resident #97 was discharged from skilled services. 4. During an interview in the Minimum Data Set (MDS) Coordinator's office on 3/11/14 at 1:45 PM, the MDS Coordinator was asked when should the ABN letters of discontinuing services have been sent to the residents. The MDS Coordinator stated, I've been sick . should have been mailed out on the 23rd instead of the 26th . | 2017-09-01 |
| 8214 | 8214 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2014-04-30 | 156 | E | 0 | 1 | CRSS11 | Based on review of facility termination of services notifications and interview, the facility failed to provide timely notification to beneficiaries of the decision to terminate covered services no later than two days before the proposed end of services for one resident (#105) and failed to notify of change in services for one resident (#169) of three residents reviewed for notification of services. The findings included: Review of the facility termination of services notification for resident #105 dated March 3, 2014, revealed, .On 3/3/14, our Utilization Review Committee reviewed (resident #105's) medical information and found the services furnished to (resident #105) no longer qualified for payment by Medicare beginning on 3/4/14 . Review of the facility termination of services notification for resident #169 dated February 1, 2014, revealed, .This letter is to notify you that on 01/31/14 (resident #169) exhausted all 100 days of (the resident's) Medicare coverage. As a result, Medicare will no longer pay for (resident #169) continued stay after this date . Interview with the Administrator of Daily Operations on April 30, 2014, at 3:45 p.m., in the conference room, confirmed the facility failed to provide notification of the decision to terminate services under Medicare prior to termination of services for resident #105 and resident #169. | 2017-07-01 |
| 8464 | 8464 | PALMYRA HEALTH CARE CENTER | 445184 | 2727 PALMYRA RD | PALMYRA | TN | 37142 | 2013-11-25 | 156 | D | 0 | 1 | 1YLU11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice for 3 of 3 (Residents #23, 40 and 41) sampled residents. The findings included: 1. Review of the NOTICE OF MEDICARE PROVIDER NON-COVERAGE form for Resident #23 documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT: SERVICES WILL END: 09/06/2013 . The form is not signed or dated by the resident or representative. 2. Review of the NOTICE OF MEDICARE PROVIDER NON-COVERAGE form for Resident #40 documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT: SERVICES WILL END: 05/15/2013 . The form is not signed or dated by the resident or representative. 3. Review of the NOTICE OF MEDICARE PROVIDER NON-COVERAGE form for Resident #41 documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT: SERVICES WILL END: 11/05/2013 . The form is not signed or dated by the resident or representative. 4. During an interview in the conference room on 11/25/13 at 4:17 PM, the Resident Assessment Coordinator (RAC) was asked why the notices were not signed. The RAC stated, I send them out by regular mail . with a self addressed stamp envelope . The RAC was asked if she had evidence that the notices were received. The RAC stated, No. | 2017-06-01 |
| 9410 | 9410 | SIGNATURE HEALTHCARE AT SAINT FRANCIS | 445149 | 6007 PARK AVE | MEMPHIS | TN | 38119 | 2013-08-01 | 156 | D | 0 | 1 | NC2111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to ensure an Advanced Beneficiary Notice (ABN) was issued to 1 of 5 (Resident #237) Medicare residents reviewed for ABN. The findings included: Record review for Resident #237 documented and admission date of [DATE]. Resident #237 was discharged on [DATE]. The facility failed to issue an ABN. During an interview in the conference room on 8/1/13 at 12:30 PM, the Administrator stated, We did not give him an ABN because we were not cutting him off. He was going home . | 2016-12-01 |
| 9822 | 9822 | CENTER ON AGING AND HEALTH | 445424 | 880 SOUTH MOHAWK DRIVE | ERWIN | TN | 37650 | 2013-03-21 | 156 | D | 0 | 1 | JVCX11 | Based on observation and interview, the facility failed to notify three residents (#84, #90, & #102) in a timely manner (no later than 2 days) of appeal rights of skilled services being termination. The findings included: Review of Liability Notices and Resident Appeal Rights (Advance Beneficiary Notice (ABNs) of three residents #84, #90, & #102, revealed no documentation the residents or their legal representative were notified of appeal rights at least two days prior to termination of skilled services. Interview with the Admission Coordinator, in the Admission office, on March 20, 2013, at 3:00 p.m., confirmed the facility haad failed to insure the residents or residents' representives were notified timely of appeal rights for termination of skilled services for resident #84, #90, and #102. | 2016-10-01 |
| 10235 | 10235 | WHITEHAVEN COMMUNITY LIVING | 445233 | 1076 CHAMBLISS ROAD | MEMPHIS | TN | 38116 | 2012-08-29 | 156 | C | 0 | 1 | RWBL11 | Based on observation and interview, it was determined the facility failed to prominently display the nursing home information posting that contained how to apply for Medicare / Medicaid benefits, contact advocacy groups and the state agency, and how to file a grievance on 4 of 4 (8/26/12, 8/27/12, 8/28/12, and 8/29/12) days of the survey. The findings included: Observations in the front lobby on 8/26/12, 8/27/12, 8/28/12, and 8/29/12 revealed no information was posted related to an application for Medicare and Medicaid, names and telephone numbers of advocacy groups or the state agency, and no complaint or grievance statement information displayed for public and resident access. During an interview in the business office on 8/28/12 at 9:45 AM, the facility Administrator was asked if the required postings were posted for public viewing. The Administrator stated, .I don't know what happened to them, they were here . There is stuff up here we don't need and then there is stuff we need that is not . | 2016-07-01 |
| 10252 | 10252 | GLEN OAKS HEALTH AND REHABILITATION | 445234 | 1101 GLEN OAKS ROAD | SHELBYVILLE | TN | 37160 | 2012-02-29 | 156 | C | 0 | 1 | 6K9O11 | Based on review of facility documentation and interview, it was determined the facility failed to notify the residents of their right to request a demand bill to appeal the denial for termination of Medicare services for 28 of 32 residents reviewed. The findings include: Review of the facility's Noncoverage of Medicare Denial letters identified that 32 residents were given notices that their Medicare coverage was to be terminated. Twenty-eight of the 32 residents had not reached the maximum benefit days allowed by Medicare (non-technical denial) and were terminated for not meeting the requirements for skilled services. Although, notification letters were sent within the required 48 hour time frame the letter failed to include the opportunity for residents to request a demand bill to appeal the denial. During an interview in the conference room on 2/29/12 at 4:30 PM, the Admission Director was asked if residents were given the choice to submit a demand bill. The Admission Director stated, .we were using the wrong form. No, the residents were not given notification of their right to request a demand bill to appeal the denial. | 2016-07-01 |
| 10977 | 10977 | LIFE CARE CENTER OF GREENEVILLE | 445228 | 725 CRUM STREET | GREENEVILLE | TN | 37743 | 2012-07-27 | 156 | D | 0 | 1 | YH5V11 | Based on interview and review of the resident's financial record the facility failed to provide Liability and Appeal notices to two dicharged residents (#61 & #160) of thirty one residents reviewed in stage 2 of the quality indicator survey. The findings included: Interview and financial record review with the Admission Coordinator in the faciity conference room on July 26, 2012, at 9:03 a.m., confirmed the facility failed to provide resident #61 and #160 with a Liability and Appeal notice. | 2016-03-01 |
| 10982 | 10982 | CHURCH HILL CARE & REHAB CTR | 445237 | 701 WEST MAIN BLVD | CHURCH HILL | TN | 37642 | 2012-08-02 | 156 | D | 0 | 1 | PZ5711 | Based on review of financial records and interview, the facility failed to provide timely Notice of Medicare Non-Coverage to one (#76) of five resident records reviewed. The findings included: Review of resident financial records revealed a Social Service note dated July 30, 2012, Medicare skilled services will end 7/31. Spoke with res. (resident's) .adult child) .and explained NOMNC (Notice of Medicare Non-Coverage) and the completion of skilled care .(adult child) verbalized understanding and will be . Interview with the Social Service Director on August 2, 2012, at 8:35 a.m., in the business office, confirmed the facility failed to give at least two full days notice and the Notice of Medicare Non-Coverage was not completed timely. | 2016-03-01 |
| 11193 | 11193 | DONELSON PLACE CARE & REHABILITATION CENTER | 445148 | 2733 MCCAMPBELL AVENUE | NASHVILLE | TN | 37214 | 2012-08-16 | 156 | D | 0 | 1 | LTRR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and interview, the facility failed to provide timely Notice of Medicare Non-Coverage to one (#79) of five resident records reviewed. The findings included: Review of resident financial records revealed Resident #79 was discharged on [DATE] due to resident reaching maximum potential with rehabilitation. Continued review revealed no documentation of a Notice of Medicare Non-Coverage was provided. Interview with the Business Office Manager on August 15, 2012 at 1:50 p.m. to 2:10 p.m., in the Business Office confirmed the facility failed to give at least two full days notice and the Notice of Medicare Non-Coverage was not completed. | 2016-02-01 |
| 11290 | 11290 | CONSULATE HEALTH CARE OF CHATTANOOGA | 445205 | 8249 STANDIFER GAP ROAD | CHATTANOOGA | TN | 37421 | 2012-10-17 | 156 | D | 0 | 1 | R9ZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, interview, and medical record review, the facility failed to provide two residents (#46, #95) of three residents reviewed with an appropriate liability and appeal notice, and failed to provide resident rights in writing for one resident (#11) of forty-three sampled residents. The findings included: Review of facility documentation for two residents #46, and #95, revealed no denial letter and the beneficiary had not been advised of his/her rights to have a claim submitted to Medicare or advise the standard claim appeal rights if the claim was denied by Medicare. Interview with the Office Manager on October 16, 2012, at 4:28 p.m., in the front office, confirmed the facility failed to provide the residents a liability and/or appeal notice. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had no cognitive impairment. Interview with the resident on October 17, 2012, at 9:00 a.m., in the resident's room, revealed the resident stated had never recieved a copy of the resident's rights and wanted a copy. Review of admission documentation and interview with the Social Worker on October 17, 2012, at 10:40 a.m., in the conference room, confirmed the resident had signed and initialed all the admission paperwork except the section indicating, I hereby acknowledge that I have received copies of the following information and that it has been clearly explained to me by the facility staff. Patient Rights . Further interview confirmed the admission documentation did not indicate the resident had received a written copy of the Patient Rights. | 2016-02-01 |
| 11321 | 11321 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2012-06-07 | 156 | E | 0 | 1 | W4VF11 | Based on review of facility documentation and interview, the facility failed to provide three residents (#32, #62, #93) of three residents reviewed with an appropriate liability and appeal notice. The findings included: Review of facility documentation for three residents #32, #62, and #93, revealed the Medicare denial letter did not include the notification of the beneficiary of his/her right to have a claim submitted to Medicare or advise of the standard claim appeal rights if the claim was denied by Medicare. Interview with the billing clerk on June 5, 2012, at 3:45 p.m., in the front office, confirmed the facility failed to provide the residents the appropriate liability and/or appeal notice. Interview with the Administrator on June 5, 2012, at 3:49 p.m., in the front office, confirmed the facility failed to provide the residents the appropriate liability and/or appeal notice. | 2016-02-01 |
| 11507 | 11507 | BELCOURT TERRACE NURSING HOME | 445273 | 1710 BELCOURT AVENUE | NASHVILLE | TN | 37212 | 2012-10-11 | 156 | D | 0 | 1 | 6IO711 | **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 an Advanced Beneficiary Notice (ABN) was issued for 1 of 3 (Resident #50) sampled residents reviewed for ABNs. The findings included: Medical record review for Resident #50 documented an admission date of [DATE] with a discharge date from Occupational Therapy 8/6/12 and a discharge date from Physical Therapy 8/7/12. Review of the Resident Census documented Resident #50 changed to medicaid from skilled services 8/8/12. During an interview in the Social Service's office on 10/9/12 at 5:50 PM, the Social Service Director (SSD) was questioned concerning the ABN notice for Resident #50. The SSD stated, .we mail forms (ABNs) to the resident's responsible party, sometimes they sign them and send them back. She (Resident #50) is still in the building, living here, met her maximum for therapy, but I can not find where one (ABN) was sent for her (Resident #50) . | 2016-01-01 |
| 11721 | 11721 | NHC HEALTHCARE, MILAN | 445069 | 8017 DOGWOOD LANE P O BOX A | MILAN | TN | 38358 | 2012-02-28 | 156 | D | 0 | 1 | V9VF11 | Based on review of Advanced Beneficiary Notices (ABN) and interview, it was determined the facility failed to ensure advanced notice of the estimated cost per day to continue services when Medicare benefits were expected to end for 3 of 3 (Resident #17 and Random Residents (RR) #4 and 5) residents reviewed for ABN. The findings included: Review of the ABN for Resident #17, RR #4 and RR #5 revealed Medicare coverage would end 2/23/12. Review of the signature page revealed no signatures of the patient or the authorized representative. During an interview in the conference room on 2/28/12 at 1:10 PM, the Social Worker (SW) was asked when the ABN notices were mailed. The SW stated, .mailed them 2/23/12. The SW was asked for any ABN letters prior to the 2/23/12 letters. The SW stated, .can't find any of last years. this is all I have. | 2015-11-01 |
| 12572 | 12572 | MAURY REGIONAL HOSPITAL SNU | 445398 | 1224 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2012-04-25 | 156 | C | 0 | 1 | YU7V11 | Based on interview, it was determined the facility failed to provide residents with liablity and/or appeal notice(s) for three Medicare beneficiaries who were discharged from the facility in the past 6 months. The findings included: During an interview in the Activity/Dining room on 4/25/12 at 3:30 PM, the surveyor asked the Administrator to provide the liability and appeal notice(s) given for 3 discharged Medicare covered residents who had days of Medicare covered services left. The Administrator stated, "...We don't do them (Liability Notices and Beneficiary Appeal Rights). At admission it is understood we are a short term facility..." During an interview in the Social Worker's office on 4/25/12 at 5:00 PM, the Social Worker was asked if she gave Medicare covered residents the required liability and/or appeal notice(s) to a resident with Medicare Skilled coverage remaining. The Social Worker stated, "...No..." | 2015-08-01 |
| 12857 | 12857 | LIFE CARE CENTER OF HIXSON | 445380 | 5798 HIXSON HOME PLACE | HIXSON | TN | 37343 | 2011-03-30 | 156 | E | 0 | 1 | 479Y11 | Based on observation, resident/family/group interview, and a review of facility information provided to residents/families at admission, the facility failed to communicate at admission and during the residents stay at the facility, information regarding visitation hours, access to private telephone conversations, availability of a la carte dining service, and personal items allowed in resident's rooms for twelve of twelve alert, oriented residents in the group interview. The findings included: Observation on the front door of the facility on March 29, 2011, at 7:30 a.m., revealed signage stating facility visitation hours were between 8:00 a.m. and 8:00 p.m. Continued observation revealed the front door was locked preventing access from the outside. Family interview on March 29, 2011, at 10:30 a.m., in a resident's room, revealed facility visiting hours are 8:00 a.m. to 8:00 p.m.; the front and side doors remain locked until 8:00 a.m., preventing family members access to residents, and family members' entrance into the building prior to 8:00 a.m. was dependent upon who answered the buzzer (attached at the outside door entrance). Continued family interview revealed if the family member was unable to gain entrance into the facility by 7:30 a.m., the resident could not get dressed in time to eat in the dining room. Group interview on March 29, 2011, at 2:00 p.m., in the Activity Room, with twelve alert, oriented residents revealed the resident's family members were unable to enter the facility prior to 8:00 a.m. Review of facility provided documents (admissions information provided to residents and families) revealed no written information was provided to residents regarding visitation hours or the ability to gain access into the facility for off hour visitation (8 p.m.-8 a.m.). Interview with the Administrator on March 30, 2011, at 2:00 p.m., in the Conference Room, revealed family members were to be allowed entry into the building if they used the buzzer, and confirmed residents and families were not provided with … | 2015-07-01 |
| 14327 | 14327 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 156 | D | LH9611 | Based on record review and interview, it was determined the facility failed to provide 2 of 3 (Residents #9 and 105) residents with an advanced beneficiary notice as required by law. The findings included: Review of advanced beneficiary notices on 5/14/12 at 1:05 PM, the facility was unable to provide an advanced beneficiary notices for Residents #9 and #105. During an interview in the Assistant Director of Nursing's (ADON) office on 5/14/12 at 1:05 PM, the Social Worker stated, "We did not start giving them (advanced beneficiary notice) until April (2012)." | 2014-01-01 | ||
| 56 | 56 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 157 | D | 0 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the Physician of a clinical complication for one resident (#168) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident was rarely/never understood. Medical record review of a nurse note by Registered Nurse (RN) #1 dated 7/18/17 at 8:50 AM revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she noticed the [MEDICATION NAME] was missing around 4 AM. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with LPN #1 on 7/19/17 at 2:55 PM via telephone revealed she worked 7/18/17 from 7 AM to 7 PM and cared for Resident #168. Further interview revealed RN #1 told her at shift change the [MEDICATION NAME] was missing. Continued interview confirmed LPN #1 intended to notify the Physician of the missing [MEDICATION NAME] but failed to do so. | 2020-09-01 |
| 400 | 400 | THE WATERS OF CLINTON, LLC | 445135 | 220 LONGMIRE RD | CLINTON | TN | 37716 | 2017-11-13 | 157 | D | 1 | 1 | UJ6N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician and family of a fall for 1 resident (#43) of 8 residents reviewed for falls, of 29 residents reviewed. The findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review of a nursing note dated 9/15/17 at 8:45 PM revealed, .Night nurse here for shift report. Night nurse taken to resident's room for report. Night nurse verbalizes understanding to this nurse's shift report. Resident lying on floor mat. Resident's eyes closed, respirations even and unlabored. Skin warm, dry and normal color . Medical record review of a nursing note dated 9/15/17 at 9:30 PM revealed, .This nurse and staff observe resident sitting on mat. Resident offered water per this nurse. Resident refuses to drink water. Resident covered with blanket for comfort. This nurse leaves room with door open due to no residents in hallway . Medical record review of the SBAR - Change of Condition (Situation, Background, Action, Response) created on 9/16/17 at 12:14 AM with an effective date (meaning the time/date of incident) of 9:07 PM, revealed, .Resident observed sitting on floor in her room. Resident was scooting across floor . Medical record review of a nursing noted dated 9/16/17 at 7:32 AM revealed, .Post Fall: Head to toe assessment - greyish/blue colored bruise & (and) swelling across forehead - tissue soft to palpate .Quarter size blue bruise with raised area top o… | 2020-09-01 |
| 529 | 529 | MAJESTIC GARDENS AT MEMPHIS REHAB & SNC | 445150 | 131 N TUCKER | MEMPHIS | TN | 38104 | 2017-08-24 | 157 | D | 0 | 1 | 5LE311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician of a significant change in status for 1 of 17 (Resident #24) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].HumaLOG Solution .Inject as per sliding scale .For blood glucose .300-349 = (equal) 20 (units); 350 + (plus) (=) 24 If BS (Blood Sugar) over 349 give 24 units and call physician, subcutaneously before meals . A physician's orders [REDACTED].inject as per sliding scale .300-349 = 20 units, 350-600 = 24units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus) . Review of the Medication Administration Records (MARs) for 7/8/17 through 7/15/17 revealed the following blood sugar levels greater than 349: 7/8/17 at 9:00 PM = 376 7/11/17 at 4:00 PM = 450 7/13/17 at 9:00 PM = 571 7/15/17 at 5:00 AM = 454 The facility was unable to provide any documentation that the physician or nurse practitioner was notified regarding the elevated blood sugar levels on 7/8/17, 7/11/17, 7/13/17, and 7/15/17. Interview with the Director of Nursing (DON) on 8/24/17 at 9:55 AM, in the restorative dining room, the DON was asked what the protocol was for elevated blood sugar levels. The DON stated, Follow physician's orders [REDACTED]. The DON was asked if the nurses should document that the physician was notified. The DON stated Yes .in the progress notes . The DON was unable to find any documentation that the physician had been notified for the elevated blood sugar levels. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 11:37 AM, in the conference room, the DNP was asked when she expected to be notified regarding elevated blood sugar levels. The DNP stated, .there are standing orders that they are supposed to ca… | 2020-09-01 |
| 604 | 604 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2017-05-10 | 157 | D | 1 | 0 | DC3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions. | 2020-09-01 |
| 720 | 720 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 157 | D | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to obtain a discharge to hospital order for 1 resident (#4) of 30 residents reviewed and failed to obtain a physician order for [REDACTED]. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 1/16/17 revealed Resident #4 was transferred to the hospital for pain. Medical record review revealed no physician order to transfer the resident to the hospital. Further review revealed a physician order dated 1/18/17 .Return from hospital . Interview with Licensed Practical Nurse (LPN) #4 on 2/14/17 at 9:04 AM in the conference room confirmed the facility failed to obtain a physician order for [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 2/13/17 at 11:00 AM and on 2/14/17 at 11:12 AM revealed a C-Pap mask stored on the bed side table in Resident #14's room. Medical record review of the physician orders revealed no order for the C-Pap setting. Interview with LPN #3 on 2/15/17 at 8:12 AM at the nursing station revealed the staff turned the machine on and off per the direction of the resident and gave him the mask to put on. Further interview confirmed the facility failed to obtain the C-Pap setting order. | 2020-09-01 |
| 1126 | 1126 | PINE MEADOWS HEALTH CARE | 445232 | 700 NUCKOLLS ROAD | BOLIVAR | TN | 38008 | 2017-05-18 | 157 | D | 1 | 1 | 7VZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician of significant changes in a resident's status for 1 of 20 (Resident #87) sampled residents of the 32 residents included in the stage 2 review. The findings included: Closed medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. Confidential QA (Quality Assurance) document - allegation of neglect (Resident #87) (undated) documented, .She stated that around 5:45-6:00 [NAME]M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday Feb (February) 2nd (YEAR) .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87)'s O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP (blood pressure) and it was 90/50. The nurse and I kept talking to (Resident #87) to try to get a response. (Resident #87) did not talk but he nodded his head in response … | 2020-09-01 |
| 1349 | 1349 | HARTSVILLE CONVALESCENT CENTER | 445256 | 649 MCMURRY BLVD | HARTSVILLE | TN | 37074 | 2017-09-12 | 157 | D | 1 | 0 | 9I4J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview, the facility failed to notify the Responsible Party of a non-abusive allegation timely for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation and a Nurse's Note dated 3/5/17 at 8:25 PM revealed Resident #2 had his pants down and was found on top of Resident #1 in bed. Further review of the facility investigation revealed Social Progress Notes dated 3/6/17 .This writer along (with) DON (Director of Nursing) called resident's daughter .this afternoon (although the event took place 3/5/17 at 8:25 PM) to let her know about the situation that happened last PM around 8:25 in her room (with) a male resident . Interview with Resident #1 on 9/11/17 at 8:48 AM and 2:00 PM in her room revealed the resident recalled Resident #2, nodded her head Yes when asked if she had affection for him and was ok with him being on top of her and doing what he did. When asked if the resident was ever afraid while he was on top of her, if he had hurt her, and if he had done anything she did not want him to do, she shook head No to each question. Interview with the Abuse Coordinator, the Social Service Director (SSD), with the DON and Administrator present, on 9/11/17 beginning at 9:30 AM in the conference room revealed the SSD informed both resident's Responsible Parties of the event. Further interview confirmed the facility failed to notify Resident #1's Responsible Party timely. | 2020-09-01 |
| 1361 | 1361 | HARTSVILLE CONVALESCENT CENTER | 445256 | 649 MCMURRY BLVD | HARTSVILLE | TN | 37074 | 2017-11-15 | 157 | D | 0 | 1 | 4ZDI11 | **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 recommendations for 1 resident (#5) of 26 residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medcial record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 9/1/17 revealed Resident #5 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Continued review of the MDS dated [DATE] and 9/1/17 revealed the resident had impaired vision and did not have corrective lenses. Medcal record review of the Care Plan for Resident #5 revealed the resident had visual deficits. Medical record review of a Request for an Eye Evaluation dated 6/13/17 revealed a request for an eye evaluation to be completed. Continued review of an eye exam evaluation completed on 6/30/17 revealed a recommendation for the resident to receive .artificial tear tid (three times per day) .Daily activities and quality of life affected. Refer for Cataract evaluation . Medical record review revealed no documetation the Physician had been notified of the recommendations nor had a cataract evaluation referral been made. Interview with Licensed Practical Nurse (LPN) #4 on 11/14/17 at 2:50 PM at the 2nd floor nurses station revealed if a referral was needed the Physician was notified and ordered the referral appointment. Interview with LPN #1 on 11/14/17 at 5:05 PM in the conference room revealed an eye exam evaluation went to the Director of Nursing (DON) and then to the floor nurse, who was responsible for contacting the Physician to notify of recommendations. Continued interview revealed documentation of the Physician notification would be in the Nurse's Notes. LPN #1 reviewed Nurse Progress Notes and confirmed there was no documentation of notification to the Physician of the recommendations. LPN #1 confirmed the facility failed to notify the Physici… | 2020-09-01 |
| 1593 | 1593 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2017-03-22 | 157 | D | 0 | 1 | BNNZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of an informal facility report, and interview, the facility failed to notify the physician and the family of a change in condition related to elopement for 1 resident (#128) of 29 residents reviewed. The findings included: Review of the facility policy Elopement Policy, revised 4/2009, revealed .Definition of Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED].family and physician notification .reports findings and condition of the resident . Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 4 (severe cognitive impairment), Delusions (1 to 3 days), Wandering (1 to 3 days), and Wandering Impact yes (indicating the wandering placed the resident at significant risk of getting to a potentially dangerous place). Medical record review of Licensed Practical Nurse (LPN) #1's Progress Note, dated 10/3/16 at 6:47 PM, revealed .Found by CNA walking outside dining room, looking at foliage. DON (Director of Nursing) notified. Q (every) 15 min (minute) checks initiated . Medical record review of an informal facility report, dated 10/3/16, revealed Resident #128 exited the building, visitors going on to their car called the DON, and reported the resident outside in front of the dining room. Continued review revealed Certified Nursing Assistant (CNA) #3 brought the resident back into the facility, the DON ordered 15 minutes checks .for the next few days . and instructed LPN #1 to notify the family and Family Nurse Practitioner. Further review revealed 15 minutes checks performed from 5:15 PM on 10/3/16 through 11:00 PM on 10/8/16. Medical record review of Resident #128's Physician Orders revealed no orders for Resident #128 for 10/3/16 … | 2020-09-01 |
| 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 |
| 2558 | 2558 | BRIGHT GLADE HEALTH AND REHABILITATION CENTER INC | 445426 | 5070 SANDERLIN AVENUE | MEMPHIS | TN | 38117 | 2017-10-26 | 157 | D | 0 | 1 | O8YD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician related to diagnostic test for 1 of 15 (Resident 14) residents of the 24 residents included in the Stage 2 sample review. The findings included: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #14 had severe cognitive impairment. An Ultrasound Requisition signed by the physician and dated 10/8/17 documented, .Reason for Exam .Wound, R/o (Rule out) [DIAGNOSES REDACTED] . The Claim Status Points form documented, .CANCELLED .10/05/2017 15:49 .Patient confused and/or combative . Interview with the Director of Nursing (DON) on 10/26/17 at 9:26 AM, in the DON office, the DON was asked if she would expect the physician to be notified if the resident refused an ultrasound . The DON stated, Yes. There was no documentation the Physician was notified of the ultrasound not being performed as ordered. | 2020-09-01 |
| 2657 | 2657 | MT JULIET HEALTH CARE CENTER | 445439 | 2650 NORTH MT JULIET ROAD | MOUNT JULIET | TN | 37122 | 2017-06-07 | 157 | D | 1 | 0 | W48711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interviews, the facility failed to notify the physician and the resident representative of a change in condition in physical status for 1 resident (#1) of 3 residents reviewed for notification of change; and failed to notify the physician of a missed medication for 1 resident (#4) of 3 residents reviewed for medication administration of 13 sampled residents. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 09/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of one for transfer, dressing, and hygiene/bathing. Review of the facility's investigation dated 2/10/17, not timed, revealed on 2/10/17 at approximately 2:45 PM a Certified Nursing Assistant (CNA) found Resident #1 with her leg elevated on a chair. Continued review revealed .she was complaining about her right leg was hurt .I told the nurse .we put her to bed . Further review revealed the resident's knee was assessed by Licensed Practical Nurse (LPN) #4 and was observed as swollen and LPN #4 instructed the CNA to lay the resident down and elevate the leg on a pillow. Medical record review of a Nurse's note dated 2/10/17 at 3:46 PM revealed the resident complained of pain in her right knee. Continued review revealed there was some swelling in the right knee with no bruising or redness noted. Further review revealed .there is a small scrape on the right knee which appears to be old .no open areas noted .right knee is tender and slightly warm to the touch . denied falling or hurting herself . Medical record review of a Nurse's note dated 2/12/17 at 9:55 PM revealed the resident's right knee was swollen. Continued review revealed .pedal … | 2020-09-01 |
| 2759 | 2759 | AHC MCNAIRY COUNTY | 445452 | 835 EAST POPLAR AVENUE | SELMER | TN | 38375 | 2017-06-28 | 157 | D | 0 | 1 | 63XQ11 | **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 physician of a significant change in condition and that the resident refused all medications necessary to treat cardiac conditions for 1 of 22 (Resident #124) sampled residents reviewed during the stage 2 review. The findings included: Review of the Documentation of Med (Medication) Pass policy dated (MONTH) 2014 revealed, The physician should be consulted and made aware if the patient is frequently refusing any or all of their meds. Medical record review revealed Resident #124 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. These medications included Aspirin 81 milligrams (mg), [MEDICATION NAME] 125 micrograms (mcg), [MEDICATION NAME] Sodium 100 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] ER(Extended Release) 50 mg, Multivitamin, and Potassium Chloride 20 milliequivalents (mEq). The Nurse's Notes dated 4/27/17 at 10:45 AM documented by Licensed Practical Nurse (LPN) #1 revealed Resident #124 spit out medications and breakfast stating that's enough. The Nurse's Notes dated 5/2/17 at 2:22 AM indicated nursing staff had difficulty administering meds (medications) this shift. Appetite poor. Increased weakness noted. There was no documentation on 4/27/17 or 5/2/17 that the physician had been notified of Resident #124 refusing to take the medications or the change in condition of a poor appetite and increased weakness. Interview with Licensed Practical Nurse (LPN) #1 on 6/27/17 at 3:55 PM in the conference room. LPN #1 stated she was familiar with Resident #124. She stated, (Resident #124) didn't take her medication that day. She would do that with food and fluids too. I would normally write it down in the doctor's book. I wouldn't call him. He comes in almost every day. We have a communication book we write things in for him. He looks at the book and then removes th… | 2020-09-01 |
| 2803 | 2803 | SWEETWATER NURSING CENTER | 445456 | 978 HWY 11 SOUTH | SWEETWATER | TN | 37874 | 2017-08-16 | 157 | D | 1 | 0 | 5ODH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to provide notification for a change in health status for 1 resident (#1) of 3 residents reviewed for notification of change. The findings included: Review of the facility policy Changes in a Resident's Condition or Status Effective Date ,[DATE] Revised ,[DATE] revealed .Nursing Services shall be responsible for notifying the Resident and responsible party when: .there is a significant change in the Resident's physical, mental, or emotional status . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] where he subsequently expired. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview of Mental Status was unable to be completed .short term memory problem .long term memory problem .moderately impaired - decisions poor; cues/supervision required . Review of the Nurse Practitioner (NP) note dated [DATE] revealed, .nurse requested visit for decline .was walking when first admitted ; now not walking. On exam resident with respiratory distress, unresponsive .CNA's (certified nurse aides) report some coughing with intake. SLP (speech language pathologist) evaluated yesterday and unable to fully participate with exam .respiratory tachypnea (rapid breathing) . Review of a Physician's Order dated [DATE], revealed, .stat 2 view CXR (chest xray), [MEDICAL CONDITION]. [MEDICATION NAME] stat (now) q (every) 6 hrs (hours) .Respiratory therapy to evaluate .) Review of the Mobile Images (chest xray) report revealed, acute right lower lobe infiltrate . Review of the NP note dated [DATE] revealed, .visit requested by Respiratory Therapy. Resident with shortness of breath and rhonchi . Interview with the Regional Client Operations Consultant on [DATE] at 4:00 PM, in the conference room confirmed expectations were the families … | 2020-09-01 |
| 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 |
| 3027 | 3027 | CORNERSTONE VILLAGE | 445483 | 2012 SHERWOOD DRIVE | JOHNSON CITY | TN | 37601 | 2017-05-17 | 157 | G | 1 | 1 | LW9W11 | **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 notify the Physician or the Nurse Practioner (NP) of poor nutritional intake, resulting in a 10.9% weight loss in a one month period (harm) for 1 resident (#51) of 4 residents reviewed for nutrition, of 46 sampled residents. The findings included: Review of the facility policy Weight Loss Intervention (undated) revealed .Weight loss intervention will be implemented for those residents experiencing a weight loss .Weight loss intervention is implemented to prevent further weight loss and to maintain/improve the resident's nutritional status .Steps .5% weight loss in 30 days .Referral to Registered Dietician, Physician . Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #51 was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Charting completed by the Certified Nurse Assistants (CNAs) dated 2/18/17 to 3/24/17 revealed Resident #51 consumed 25% or less for 71 of 102 meals, and 18 meals had no documentation if the resident consumed any of the meal. Medical record review of the laboratory results dated [DATE] revealed a hemoglobin of 11.5 (normal 13.5 - 17.5) and a hematocrit of 34.2 (normal 38.0 - 50.0), indicating the resident was anemic (low iron). Medical record review of the Physician Standing Orders signed by the resident's physician on 2/22/17 revealed .Weekly weights X (times) 4 weeks on admission, if stable then monthly . Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #51 was severely cognitively impaired, and the resident required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Continued review revealed Resident #51 was total dependence for transfer, eating… | 2020-09-01 |
| 3248 | 3248 | PAVILION-THS, LLC | 445500 | 1406 MEDICAL CENTER DRIVE | LEBANON | TN | 37087 | 2017-09-07 | 157 | D | 0 | 1 | OECK11 | **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 notify the physician of the family's request to hold a medication order for 1 resident (#65) of 27 residents reviewed. The findings included: Review of facility policy, Change in a Resident's Condition of Status, revised 4/5/16 revealed .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A need to alter the resident's medical treatment significantly . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #65 was severely cognitively impaired. Medical record review of a Physician's Telephone Orders Audit dated 7/24/17 revealed .(1) taper off [MEDICATION NAME] (antidepressant) QOD (every other day) x (times) 1 wk (week), then DC (discontinue), (2) [MEDICATION NAME] (antidepressant) 50 mg (milligrams) . Medical record review of the 7/2017 through 8/2017 Medication Review Report revealed an order dated 8/8/17 for [MEDICATION NAME] 100 mg every other day for 1 week then DC and an order dated 8/8/17 for [MEDICATION NAME] 50 mg. Interview with Licensed Practical Nurse (LPN) #2 on 9/6/17 at 4:05 PM at the 100/200 hall nursing station confirmed she wrote the Physician's Telephone Orders Audit dated 7/24/17 for Resident #65. Further interview revealed the resident's daughter requested the 7/24/17 order be held until the daughter was able to review the genetic testing results for the resident. Continued interview with LPN #2 confirmed the facility failed to notify the prescribing Physician for clarification of the medication order. Interview with Director of Nursing (DON) on 9/6/17 at 4:20 PM in her office confirmed the facility failed to notify the prescribing Physician for clarification of the medication order dated 7/24/17 for Resident #… | 2020-09-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );