cms_TN
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14,361 rows sorted by facility_name
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4850 | 4850 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2016-04-13 | 441 | E | 0 | 1 | 1NKU11 | Based on observation and interview, the facility failed to store biohazard waste in a sanitary manner for one of two biohazard rooms observed. The findings included: Observation of wound care with the Wound Care Nurse on 4/13/16 at 9:27 AM, revealed the Wound Care Nurse completed a dressing change and placed visibly soiled items in a red biohazard bag. Continued observation revealed the Wound Nurse took the bag containing the biohazard items to a room labeled soiled utility, and then placed the biohazard items in a large wheeled plastic container. Further observation of the container revealed there was no red biohazard bag in the container; and there was a visibly soiled towel on the bottom of the container, multiple loose gloves, and a broke plastic fork. Interview with the Wound Care Nurse on 4/13/16 at 9:39 AM, confirmed the facility failed to follow infection control practice by not disposing of the biohazard items in an approved manner. | 2019-07-01 |
| 8681 | 8681 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 278 | D | 0 | 1 | GOZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately identify pressure ulcers on the Admission Minimum Data Set (MDS) dated [DATE], for one resident (#91) of four residents reviewed for pressure ulcers. The findings included: Resident #91 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Weekly Wound Assessment Progress Note dated October 7, 2013, revealed .Lt (left) heel /c (with) 2 (two) sDTIs (Suspected Deep Tissue Injury). Areas are purple, intact blister. Tissue is mushy .Rt (right) heel /c DTI. Area is purple /c mushy, intact blister present .Stage One pressure ulcers present to bilateral ischial tuberosities . Medical record review of the MDS dated [DATE], revealed no pressure ulcers were documented. Interview with the MDS Coordinator, on November 20, 2013, at 1:35 p.m., in the MDS office, confirmed there no pressure ulcers were documented on the Admission MDS, and the MDS was inaccurate. | 2017-05-01 |
| 8682 | 8682 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 281 | D | 0 | 1 | GOZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the meal intake record, facility policy review, and interview, the facility failed to weigh a resident weekly after admission and failed to reweigh the resident after a weight discrepancy for one resident (#224), of twenty residents reviewed. The findings included: Resident #224 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on November 19, 2013, at 12:30 p.m., and on November 20, 2013, at 8:30 a.m., revealed the resident in the resident's room self feeding the meals. Further observation revealed the resident consumed 75-100 percent of both meals observed. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was moderately cognitively impaired and was independent with eating after set-up. Medical record review of the hospital data dated October 28, 2013, revealed the resident's initial weight was 64.5455 kilograms (142 pounds). Medical record review of the admission nursing assessment dated [DATE], revealed the resident's weight was 161 pounds, had bilateral lower extremity [MEDICAL CONDITION], and had complaints of difficulty/pain with swallowing. Medical record review of the Nursing Progress Notes dated November 2-10, 2013, revealed the resident had bilateral lower extremity [MEDICAL CONDITION], TED hose (compression device) worn, legs elevated on pillow, and/or bilateral heels off loaded. Medical record review of the Weight Record revealed the admission weight was 161 pounds and the usual body weight was 142 pounds at home. Further review of the Weight Record dated November 13, 2013, revealed the resident's weight was 140 pounds, a decrease of 21 pounds in fourteen days. Review of the meal intake record revealed the resident consumed 75-100 percent of every meal after November 11, 2013. Medical record review revealed the resident was ordered a speech therapy evaluation and treatment at admission and the… | 2017-05-01 |
| 8683 | 8683 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 371 | F | 0 | 1 | GOZW11 | Based on observation and interview, the facility failed to store food under sanitary conditions and failed to maintain a clean and sanitary kitchen. The findings included: Observation on November 18, 2013, at 7: 20 p.m., in the kitchen revealed on the shelving unit next to the steam table: 1. An unsealed open package of Quick Oats. 2. Two unsealed and opened packages of Creme of Wheat. 3. An unsealed and opened package of Grits. 4. An unsealed and opened box of baking soda. 5. An unsealed and opened package of Creole Seasoning. 6. An unsealed and opened package of White Rice. 7. An unsealed and opened package of Brown Rice. 8. One bottle of Heinz 57 Sauce with the cap opened. Further observation in the kitchen on August 18, 2013, at 7:30 p.m.,revealed: 1. The third bin of the steam table had food debris floating in the water. 2. In the walk-in refrigerator a pan of partially cooked pork tips was not fully covered or sealed with plastic wrap and the meat was exposed. Stored on top of and touching the partially cooked pork tips was a fully cooked pork wrapped in foil. 3. Two convection ovens with dark brown flaky debris on the interior. 4. A deep fryer filled with black oil uncovered with debris floating on the top of the oil. Interview with dietary personnel #1 on November 18, 2013, at 7:40 p.m., in the dietary office confirmed the facility failed to store food properly and maintain a clean and sanitary kitchen. | 2017-05-01 |
| 8684 | 8684 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 441 | D | 0 | 1 | GOZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain clean oxygen concentrator filters for one resident (#217) of twenty residents reviewed. The findings included: Resident #217 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED].oxygen per nasal cannula at 2-3 liters to keep saturation greater than 88 percent . Observation on November 19, 2013, at 8:36 a.m., in the resident's room revealed the resident in bed with a nasal cannula in place and the oxygen concentrator in operation. Further observation revealed both filters on the oxygen concentrator were white with debris. Interview, on November 20, 2013, at 8:36 a.m., with Registered Nurse #1, in the resident's room, confirmed both oxygen concentrator filters were dirty. Further interview confirmed they should have been cleaned. | 2017-05-01 |
| 8685 | 8685 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 456 | D | 0 | 1 | GOZW11 | Based on observation and interview, the facility dietary department failed to maintain a pressure steamer in safe operational condition and created a safety hazard for dietary employees. The findings included: Observation on November 20, 2013, at 7:30 a.m., in the dietary department revealed an approximately four inch wide stream of water from the pressure steamer running on the floor to the trayline in operation. Further observation revealed dietary staff walking in and through the area of the water. Interview on November 20, 2013, at 7:30 a.m., with the dietary chef present during the observation, revealed the pressure steamer had .been leaking a long time . Interview on November 20, 2013, at 7:45 a.m., with the Certified Dietary Manager, by the pressure steamer, confirmed the steamer was leaking onto the floor and the water was crossing the floor to the trayline area. | 2017-05-01 |
| 10756 | 10756 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 241 | D | 0 | 1 | W8Q911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure staff asked permission or knocked on doors before entering resident rooms for two residents (#236, #242) of thirty- six sampled residents. The findings included: Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 16, 2012, revealed identified problems areas of impaired vision, balance, and inability to ambulate. Medical record review of the Nurse's Note dated October 21, 2012, revealed alert and oriented. Medical record review of a psychosocial assessment dated [DATE], revealed the resident was cognitively intact. Observation on October 23, 2012, at 7:40 a.m., in the hallway, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room. Resident # 242 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 18, 2012, revealed the resident had impaired functional mobility and was at risk for musculoskeletal discomfort. Medical record review of an Admission note dated October 19, 2012, revealed the resident was alert and oriented. Observation on October 23, 2012, at 7:48 a.m., in the resident's room, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room. | 2016-05-01 |
| 10757 | 10757 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 278 | D | 0 | 1 | W8Q911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide accurate information for the Minimum Data Set (MDS) assessment for one resident (#30) of thirty-seven residents reviewed. The findings included: Resident #30 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Dietary Progress Note dated May 28, 2012, revealed the resident had a gastrostomy feeding tube, and received nothing by mouth (NPO). Medical record review of the admission MDS dated [DATE], revealed the resident required extensive assist of one person for eating, and received 51% or more percent intake by artificial route (gastrostomy tube feeding). Medical record review of the 30 day MDS dated [DATE], revealed the resident was dependent on staff for eating. Continued review revealed the resident received 51% or more percent intake by artificial route (gastrostomy feeding tube). Interview with the MDS Coordinator in the private dining room on October 24, 2012, at 9:55 a.m., confirmed the resident had received nothing by mouth, and nutritional support had been provided through the use of the feeding tube. Continued interview confirmed the resident's 5 day/Admission MDS dated [DATE], was inaccurate. | 2016-05-01 |
| 10758 | 10758 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 323 | D | 0 | 1 | W8Q911 | Based on observation and interview, the facility failed to secure soiled and biohazardous materials from the resident population. The findings included: Observation during initial tour on October 22, 2012, at 10:00 a.m., revealed a Certified Nurse Assistant (CNA) entered the soiled utility room and discarded soiled linen into containers. Continued observation revealed the door to the soiled utility room did not latch after the CNA entered the room to dispose of soiled linens. Observation on October 22, 2012, at 10:05 a.m., with Licensed Practical Nurse #2 (LPN), revealed LPN #2 attempted to restore the door to the locked position, but was unable to engage the latch. Interview with LPN #2 on October 22, 2012, at 10:05 a.m., confirmed the soiled utility room contained soiled linens and biohazard containers. Continued interview confirmed the door was not working properly, and should have latched and locked automatically when closed. | 2016-05-01 |
| 10759 | 10759 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 356 | D | 0 | 1 | W8Q911 | Based on observation and interview, the facility failed to post nurse staffing data on a daily basis. The findings included: Observation on October 22, 2012, at 10:45 a.m., revealed the posted nurse staffing data was dated October 16, 2012. Observation and interview at this time with the Assistant Director of Nursing , in the skilled nurse's station, revealed the last posted nurse staffing data was on October 16, 2012, and confirmed the nurse staffing data was not posted for October 22, 2012. | 2016-05-01 |
| 10760 | 10760 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 372 | D | 0 | 1 | W8Q911 | Based on observation and interview, the facility failed to maintain the exterior dumpster area in a sanitary manner. The findings included: Observation on October 22, 2012, at 10:00 a.m., with the Certified Dietary Manager (CDM) present, revealed two exterior dumpsters with several pieces of a broken watermelon shell and pink and green debris on the concrete surface in front of the dumpsters. Interview with the CDM on October 22, 2012, at 10:00 a.m., by the exterior dumpsters, confirmed the concrete in front of the dumpsters had pieces of watermelon shell and pink and green debris present and should maintain a clean dumpster area. Observation on October 24, 2012, at 9:40 a.m., with the CDM present, revealed watermelon shell and pink and green debris present on the concrete in front of both exterior dumpsters. Further observation revealed paper plates, napkins, straws, and styrofoam cups on the concrete surface behind the dumpsters. Interview with the CDM on October 24, 2012, at 9:40 a.m., by the exterior dumpsters, confirmed the concrete surface in front of the dumpsters contained watermelon shell, pink and green debris, and paper debris behind the dumpsters. | 2016-05-01 |
| 10761 | 10761 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2012-10-24 | 441 | D | 0 | 1 | W8Q911 | Based on observation, facility policy review, and interview, the facility failed to ensure staff washed hands after medication administration; and failed to maintain infection control during blood glucose monitoring for two residents (#236, #228) of four residents reviewed for blood glucose monitoring of thirty-six sampled residents. The findings included: Observation of a medication administration on October 24, 2012, at 8:35 a.m, revealed Licensed Practical Nurse #1 (LPN) administered medications to resident #224. Continued observation revealed after the LPN administered the medications, returned to the medication cart, retrieved a stethoscope and proceeded to resident #234's room without washing the hands. Interview on October 24, 2012, at 9:00 a.m., with LPN #1, in the hallway, confirmed the nurse failed to wash the hands after administering the medications and prior to entering the resident's room Observation on October 23, 2012, at 7:40 a.m., on the 1200 hallway, revealed Registered Nurse (RN) #1 retrieved a blood glucose monitor from the medication cart, entered resident #236's room, placed the glucose monitor on the bedside table without a protective barrier. Continued observation at this time revealed RN #1 performed a blood glucose test for the resident, exited the resident's room, and placed the blood glucose monitor on the medication cart. Observation on October 23, 2012, at 7:44 a.m., on the 1200 hallway, revealed Registered Nurse (RN) #1 retrieved a blood glucose monitor from a drawer of the medication cart and placed the glucometer on top of the cart. Continued observation at this time revealed RN #1 entered resident #228's room, placed the glucose monitor on the resident's food tray without a protective barrier, performed a blood glucose test for the resident, exited the room, and placed the blood glucose monitor on the medication cart. Review of facility policy, Maintaining Glucometer, revealed .infection control standards will be maintained . Interview with RN #1 on October 23, 2012, at 7:45 a.m… | 2016-05-01 |
| 13381 | 13381 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2011-05-11 | 371 | F | 0 | 1 | 7FV811 | Based on observation and interview the facility failed to maintain the dietary equipment in a sanitary manner. The findings included: Observation on May 9, 2011, beginning at 9:45 a.m., with the executive chef present, revealed the following: 1.) The four burner range top spill pan was foil lined with a heavy greasy layer of burnt black debris under the foil and on the surface of the foil. 2.) The four burner range back splash had an area of black burnt debris present. 3.) The four burner range had a grill. The left side and the rear of the grill surface had an accumulation of blackened debris present. 4.) The six burner range back splash had an accumulation of blackened debris present. Interview on May 9, 2011, beginning at 9:45 a.m., with the executive chef, confirmed the four burner range top spill pan had a heavy greasy layer of burnt black debris under the foil and on the surface of the foil that lined the spill pan. Further interview confirmed the four burner range back splash had an area of black burnt debris. Further interview confirmed the left side and the rear of the grill surface had an accumulation of blackened debris on the four burner range unit. Further interview confirmed the six burner range back splash had an accumulation of blackened debris. | 2015-02-01 |
| 13382 | 13382 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2011-05-11 | 425 | D | 0 | 1 | 7FV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, pharmacy record review, and interview, the facility pharmaceutical service failed to dispense the quantity of Coumadin required for one resident (#6) of eighteen resident records reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review of the physician telephone order dated April 29, 2011, revealed "...Coumadin 7.5 mg po on Tuesday, Thursday, Saturday, Sunday..." Review of the pharmacy Fill History Form revealed the pharmacy dispensed ten doses of Coumadin 7.5 mg on April 22, 2011. Further review revealed the ten doses would meet the patient's needs for April 22 through May 3, 2011, per physician orders. Interview by speaker phone with Licensed Practical Nurse #1 (LPN) on May 10, 2011, at 2:35 p.m., with the facility unit manager and Director of Nursing present revealed LPN #1 did not have Coumadin 7.5 mg available in the medication cart for May 5 and 7, 2011. Further interview confirmed LPN #1 had not notified the pharmacy of the lack of medication. Interview by speaker phone with the LPN #2 on May 10, 2011, at 11:45 a.m., with the facility unit manager present revealed LPN #2 did not have Coumadin 7.5 mg available in the medication cart for May 8, 2011. Further interview confirmed LPN #2 had not notified the pharmacy of the lack of medication. Interview with the Director of Nursing on May 11, 2011, at 7:40 a.m., in the private dining room confirmed the pharmacy failed to dispense the quantity of Coumadin necessary to meet the patient's need as ordered by the physician. | 2015-02-01 |
| 14325 | 14325 | ADAMSPLACE, LLC | 445392 | 1927 MEMORIAL BOULEVARD | MURFREESBORO | TN | 37129 | 2013-11-20 | 246 | D | GOZW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to maintain a call light within reach for one resident (#223) of twenty residents reviewed. The findings included: Resident #223 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated November 11, 2013, revealed the resident had a potential for falls/injury related to history of falls, decreased mobility, weakness, with the approach to keep the call light within reach. Observation and interview with the resident, on November 19, 2013, at 8:26 a.m. revealed the resident seated in a wheelchair in the resident's room with the breakfast tray on the over bed table in front of the resident. Further observation revealed the call light was on the bed side table directly behind the wheelchair and out of reach of the resident. Interview with the resident revealed the resident was not able to reach the call light. Interview on November 20, 2013, at 8:30 a.m., with the resident's direct care Certified Nurse Aide #1, in the resident's room, confirmed the resident was capable of using the call light. Further interview confirmed the call light was not in reach of the resident. | 2014-01-01 | ||
| 2381 | 2381 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 550 | D | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to promote a resident's dignity while providing personal care for 1 of 22 (Resident #74) sampled residents. The findings included: The facility's Quality of Life -Dignity policy documented, .Bodily Privacy During Care and Treatment .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the room, removed the resident's brief, turned and repositioned the resident. CNA #1 left Resident #74 fully exposed, with no cover. CNA #1 did not request permission from the resident to proceed with personal care. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to leave a resident fully exposed during personal care. The DON stated, No. | 2020-09-01 |
| 2382 | 2382 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 690 | D | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 1 of 1 (Resident #59) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Cath (catheter) care (with)soap et (and) H2O (water) q (every) shift . Observations in Resident #59's room on 1/28/18 at 4:40 PM, revealed Certified Nursing Assistant (CNA) #3 performed catheter care for Resident #59 using plain water. CNA #3 then retrieved a urinal containing a small amount of yellow liquid and emptied the catheter drainage bag into the urinal. CNA #3 tapped the spigot of the urinary drainage bag on the inside of the urinal during drainage. Interview with the Director of Nursing (DON) on 2/1/18 at 9:10 AM, in the conference room, the DON was asked what she expected staff to use for catheter care. The DON stated, Soap and water. The DON confirmed plain water was not acceptable. | 2020-09-01 |
| 2383 | 2383 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 693 | D | 0 | 1 | YE7V11 | Based on Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, observation and interview, the facility failed to ensure management of a tube feeding was preformed by qualified personnel for 1 of 1 (Resident #74) residents reviewed with a feeding tube. The findings included: Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition page 110, documented, Nursing Intervention for People Receiving Enteral Nutrition. In caring for people with tube feedings, it is the nurse's responsibility to .administer the correct amount and type of feeding at the correct rate . Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the resident's room to turn and reposition the resident. CNA #1 immediately went to the feeding pump and put it on hold. When CNA #1 completed resident care, she reumed the feeding pump. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to put a feeding pump on hold and then resume the feeding. The DON stated, No | 2020-09-01 |
| 2384 | 2384 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 812 | F | 0 | 1 | YE7V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by improper storage of food in a cooler, expired food products, and a dirty deep fat fryer. The facility had a census of 79 with 77 of those residents receiving a meal tray from the kitchen. The findings included: Observations in the kitchen on [DATE] beginning at 8:00 AM, revealed the following: (a) 1 large package of bologna with an opening in the side of the package. Interview with the Certified Dietary Manager (CDM) on [DATE] at 8:15 AM, in the kitchen, the Dietary Manager confirmed the integrity of the package of bologna was broken. Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: (a) 2 cartons of fat free milk dated [DATE] in the milk cooler. (b) 1 carton of fat free milk dated [DATE] in the milk cooler. (c) 2 bottles of protein beverages dated [DATE] in the milk cooler. Interview with the CDM on [DATE] at 11:13 AM, in the kitchen, the CDM confirmed the milk and protein beverage were out of date and stated, .I know they are not supposed to be in there. (d) The deep fat fryer had black grease and food particles on top of the grease. Interview with the CDM on [DATE] at 11:16 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, It is due to be changed . (e) 1 container of vanilla pudding with an use by date of [DATE] in the reach-in cooler. Interview with the CDM on [DATE] at 11:20 AM, in the kitchen, the CDM stated,That should have gone out. The CDM removed it from the cooler. Observations in the kitchen on [DATE] at 11:17 AM, revealed the following : (a) The deep fat fryer had black grease with food particles on top of the grease. Interview with the CDM on [DATE] at 11:19 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, Yes, ma'am it is dirty . Interview with the CDM on [DATE] at 11:19 AM, i… | 2020-09-01 |
| 2385 | 2385 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-02-01 | 880 | D | 0 | 1 | YE7V11 | Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN #1) nurses followed practices to prevent the potential spread of infection during medication administration. The findings included: The facility's Equipment Cleaning, Disinfecting and Maintenance policy documented, .The following equipment is cleaned/disinfected after each resident use and when visibly soiled (the list includes examples of multi-use items .Stethoscopes .after use . Observations in Resident #74's room on 1/31/18 at 1:14 PM, revealed LPN #1 went to the medication cart, retrieved a stethoscope, placed the stethoscope around her neck and returned to the bedside. LPN #1 placed the stethoscope on the Resident #74's abdomen, administered medication, and laid the stethoscope on the unsanitized overbed table. Then LPN #1 left the room, carried the stethoscope and laid it on the top of the unsanitized medication cart. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 2/1/18 at 1:37 PM, in the conference room, the DON was asked should a stethoscope be cleaned before or after administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Yes. | 2020-09-01 |
| 2386 | 2386 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 600 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of [NAME] F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to ful… | 2020-09-01 |
| 2387 | 2387 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 657 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of [NAME] A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objecti… | 2020-09-01 |
| 2388 | 2388 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 689 | J | 1 | 0 | 98W311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wand… | 2020-09-01 |
| 2389 | 2389 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 835 | J | 1 | 0 | 98W311 | > Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .g… | 2020-09-01 |
| 2390 | 2390 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 865 | J | 1 | 0 | 98W311 | > Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the… | 2020-09-01 |
| 2391 | 2391 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-08-30 | 609 | D | 1 | 0 | BV6Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed… | 2020-09-01 |
| 2392 | 2392 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 550 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 23 (Certified Nursing Assistant (CNA) #1, #4, #6, #7, and #9) facility staff members referred to clothing protectors as bibs, did not use courtesy titles to address residents, used a personal cell phone while assisting a resident with a meal, stood over a resident to assist with a meal, and failed to knock before entering a resident's room. The findings included: 1. The facility's Assisting with Meals policy documented, .Residents shall receive assistance with meals in a manner that meets the individual needs .not standing over residents while assisting them with meals .avoiding the use of labels .bibs . The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .shall be treated with dignity and respect at all times .staff shall knock and request permission before entering residents' room .Staff shall speak respectfully to residents at all times .addressing the resident by his or her name of choice and not 'labeling' .demeaning practices and standards of care that compromise dignity are prohibited .promote dignity . 2. Observations in the 400 Hall Dining Room on 10/14/19 at 12:10 PM, revealed CNA #7 stated to Resident #57, .the bib is cold, isn't it . Observations in the 400 Hall Dining Room on 10/14/19 at 12:17 PM, revealed CNA #6 stated to Resident #57, .that's your food, baby . Observations in Resident #63's room on 10/15/19 at 5:15 PM, revealed CNA #4 looked at her cell phone while she assisted Resident #63 with her meal. Observations in the 200 Hall on 10/15/19 at 5:40 PM, revealed CNA #1 entered Resident #16's room to deliver his meal tray without knocking. Observations in the 200 Hall on 10/15/19 at 5:44 PM, revealed CNA #1 entered Resident #64's room to deliver his meal tray without knocking. CNA #1 then left the room, returned at 5:50 PM, and entered again without knocking. Observations in Resident #243's room on 10/16/19 at 12:40 PM, revealed CNA #9 s… | 2020-09-01 |
| 2393 | 2393 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 565 | E | 0 | 1 | PSHT11 | Based on observation and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: Observations in the Sunroom on 10/15/19 at 10:00 AM, revealed the Resident Council Meeting location was not completely private. A bi-fold screen was used to block the entrance from hall 500 to the Sunroom but was accessible to anyone on the 500 Hall. During the meeting there were three interruptions: a. A resident on the 500 Hall folded the bi-fold screen, wheeled through the Sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. b. A Certified Nursing Assistant (CNA) from the 500 Hall folded the bi-fold screen, wheeled a resident through the sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. c. The Activity Director entered the room during the meeting and assisted one of the residents to leave the room. Interview with Activity Assistant #2 on 10/17/19 at 9:36 AM in the 400 Hall, Activity Assistant #2 stated, The Resident Council Meeting should never be interrupted. | 2020-09-01 |
| 2394 | 2394 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 577 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure the survey results were readily accessible for all residents residing in the facility. The facility had a census of 98 residents. The findings include: 1. The facility's undated Resident Rights policy documented, .results of the most recent survey of the Center conducted by Federal or State surveyors and any plan of correction in effect to the Center. The Center must make the results available for examination in a place readily accessible to residents . 2. Observations in the Lobby on 10/14/19 at 9:05 AM and 10/15/19 at 11:42 AM, revealed a white binder labeled .Survey Results The results from surveys on 6/10/19, 7/2/19, and 8/30/19 were not available for the residents to review. Interview with the Administrator on 10/16/19 at 4:46 PM, in the Lobby, the Administrator was asked if the survey results were in the survey book from the surveys conducted (June, July, and Sept of 2019). The Administrator stated, .no they are not in there . The Administrator was asked if the survey results should be in the book available for residents to review. The Administrator stated, .yes . | 2020-09-01 |
| 2395 | 2395 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 658 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 1 of 2 nurses (Licensed Practical Nurse (LPN) # 4) failed to follow facility policy for administration of medications through a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for nutrition and medication) when medications were pushed through the enteral tube and not allowed to flow per gravity. The findings included: The facilities Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .Administer medication by gravity flow . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Thera liquid give 10 ml (milliliter) .peg .once a day .[MEDICATION NAME] formula capsule .once daily . The physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet per peg . The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram)/5 ml susp (suspension) give 7 ml .PEG 2 TIMES DAILY @ (at) 6 AM & (and) 6 pm . Observations in Resident #35's room on 10/15/19 at 5:09 PM, revealed LPN #4 poured 60 ml of water into Resident #35's PEG and pushed the water through the tube with the plunger. LPN #4 then administered the medications with water and pushed each medication through the tube with the plunger. LPN #4 poured 60 mL of water into the PEG tube and pushed the water through the tube with the plunger. LPN #4 did not allow the medications to flow by gravity, in accordance with the facility's policy. Interview with the Director of Nursing (DON) on 10/17/19 at 7:15 PM, in the Conference Room, the DON was asked should medications be pushed through a PEG tube. The DON stated, .no .should be by gravity . | 2020-09-01 |
| 2396 | 2396 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 684 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for wound care treatments for 1 of 4 (Resident #70) sampled residents reviewed for wound care. The findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #70 required staff assistance for all activities of daily living, and had Moisture Associated Skin Damage (MASD). The care plan dated 2/25/19 documented, .at risk for skin breakdown r/t (related to) decreased mobility, incontinence .Intervention .Treatments as directed . The Physician's Orders dated 10/7/19 documented, .Start Date .10/03/19 .RLE (Right Lower Extremity) AND LLE (Left Lower Extremity) EXCORIATION .CLEAN C (with) NS (Normal Saline), APPLY SSD (Silver [MEDICATION NAME])/[MEDICATION NAME]/[MEDICATION NAME]/ZINC TRIPLE CREAM EQUAL MIXTURE TO AFFECTED AREAS DAILY ET (and) PRN (as needed) X (times) 14 DAYS, THEN RE-EVALUATE . The Wound Assessment Report dated 10/15/19 documented, .MASD .apt (appointment) (with) .wound clinic on 10/15/19 .N.O. (new order) Cont (Continue) to apply SSD/[MEDICATION NAME]/[MEDICATION NAME]/zinc combined triple cream equal parts to affected areas daily . Observations in Resident #70's room on 10/16/19 at 10:55 AM, revealed Licensed Practical Nurse (LPN) #1 performed wound care to raised reddened areas to Resident #70's bilateral posterior upper thighs. LPN #1 wiped the wound with Aloe disposable wipes, and then applied SSD 1 percent (%) cream to the area. Interview with LPN #1 on 10/17/19 at 6:51 PM, in the 500 Hall, LPN #1 confirmed she applied SSD 1% cream to Resident #70's MASD wounds. LPN #1 was asked if the treatment was administered as ordered. LPN #1 stated, .This is what they sent from (Named Pharmacy) . Interview with the Director of Nursing (DON) on 10/17/19 at 6:54 PM, in the 500 Hall… | 2020-09-01 |
| 2397 | 2397 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 725 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility staffing schedules and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had a census of 98 residents. The findings include: 1. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #31 on 10/14/19 at 3:07 PM, in Resident #31's room, Resident #31 was asked about staffing at the facility. Resident #31 stated, Not at night time especially. They say it's just 1 or 2 (staff members) at night. Resident #31 was asked if he had to wait a long time for someone to help him if he called for help. Resident #31 stated, .takes an hour or 2 and sometimes 3 or 4, takes a long time . Even sometimes in the daytime they don't come as quick as they should. 2. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #29 on 10/14/19 at 3:58 PM, in Resident #29's room, Resident #29 was asked about staffing at the facility. Resident #29 stated, Sometimes at night it's pretty bad, especially at bedtime .have to wait at least 30 minutes before they can go to bed .sometimes at night it's way more than 30 minutes . 3. Review of the admission MDS dated [DATE] revealed Resident #143 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #143 on 10/15/19 at 8:09 AM, in Resident #143's room, Resident #143 was asked about staffing at the facility. Resident #143 stated, A lot of times at night we only have 1 aide for 30-something patients .they (call lights) might go off 30 minutes to an hour before they're answered. 4. During the Resident Council Group meeting, which consisted of 12 alert and… | 2020-09-01 |
| 2398 | 2398 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 757 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the PHYSICIANS' DESK REFERENCE 69th EDITION, medical record review, observation, and interview, the facility failed to ensure medications administered were appropriately monitored for adverse effects for 1 of 6 (Resident #16) sampled residents reviewed for unnecessary medications. The findings include: 1. The PHYSICIANS' DESK REFERENCE 69th EDITION (YEAR) documented, .[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication) .INDICATIONS AND USAGE .[MEDICAL CONDITION] .Pituitary TSH ([MEDICAL CONDITION] Stimulating Hormone) Suppression .PRECAUTIONS .has a narrow therapeutic index .Regardless of the indication for use, careful dosage titration is necessary to avoid the consequence of over- or under-treatment .These consequences include .effects on .cardiovascular function, bone metabolism .cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism .The adequacy of therapy is determined by periodic assessment of appropriate labortory tests .frequency of TSH monitoring during [MEDICATION NAME] dose titration .is generally recommended at 6-8 week intervals until normalization .When the optimum replacement dose has been attained .It is recommended .a serum TSH measurement be performed at least annually . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Unspecified Sequelae of Other [MEDICAL CONDITION] Disease. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision for all activities of daily living. A hospital discharge summary report dated 3/21/18 documented, .TSH ([MEDICAL CONDITION] Stimulating Hormone) .2/28/2018 .Result .6.44 .H (High) .Reference Range .0.45 - 5.0 .ulU/ml (micro-international units per milliliter) . The physician's orders [REDACTED].Start Date .6/30/18 .[MEDICATION NAME] 0.025 MG (milligrams) TABLET by mouth @ … | 2020-09-01 |
| 2399 | 2399 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 759 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the JoVE Science Education Database Nursing Skills. Preparing and Administering Intramuscular Injections, medical record review, observation, and interview, the facility failed to ensure 2 of 8 (Licensed Practical Nurse (LPN) #2 and #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings included: 1. The JoVE Science Education Database. Nursing Skills Preparing and Administering Intramuscular Injections documented, .The deltoid site (upper arm) .immunizations .maximum volume should never exceed 2 mL (milliliters) . The facilty's Administering Medications policy revised (MONTH) 2019 documented, .Medications are administered in a safe and timely manner, and as prescribed .The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 120 mg (milligram) IM (intramuscular) q (every) 12 hrs (hours) x (for) 14 days . Observations in Resident #18's room on 10/16/19 at 9:15 AM, revealed LPN #2 injected 3 ml of [MEDICATION NAME] into Resident #18's left upper arm (deltoid site). Interview with the Director of Nursing (DON) on 10/17/19 at 8:23 PM, in the Conference Room, the DON was asked is it acceptable to give 3 ml of medication Intramuscular (IM) in the upper arm. The DON stated, .no . Failure of LPN #2 to administer an IM injection of [MEDICATION NAME] of less than 2 ml into the deltoid site resulted in medication error #1. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .1… | 2020-09-01 |
| 2400 | 2400 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 760 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information, policy review, medical record review, and interview, the facility failed to ensure medications were administered free from significant medication errors for 1 of 24 (Resident #70) sampled residents. The findings include: 1. The (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information documented, .Take [MEDICATION NAME] once a day . 2. The facility's Medication and Treatment Orders policy with a revision date of 7/2016, documented, .Orders for medications must include .Dosage and frequency of administration .Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders . 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 2/25/19 documented, .insulin dependent diabetic .at risk for hypo/[MEDICAL CONDITION] and complications of the disease .Intervention .Medications .as directed per MD (Medical Doctor) .orders . The Physician admission orders [REDACTED].[MEDICATION NAME]-5mg (milligrams)-take 1 tab (tablet) po (by mouth) before meals . The Telephone physician's orders [REDACTED].Order Clarification .[MEDICATION NAME] 5mg po (by mouth) QD (every day) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 Monthly Consultant Pharmacist Report documented, .Please note the following medication(s) are dosed above the usual geriatric dosage .[MEDICATION NAME] 5mg tid (three times daily) .Recommendation .[MEDICATION NAME] 5mg daily . Telephone interview with the Pharmacist on 10/17/19 at 8:52 AM, the Pharmacist was asked if there had been a problem with Resident #70's diabetic medication, [MEDICATION NAME]. The Pharmacist stated, Yes .There's no way they are supposed to be given three times a day .it w… | 2020-09-01 |
| 2401 | 2401 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 761 | D | 0 | 1 | PSHT11 | Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 9 (500 Lower Hall Medication Cart) medication storage areas was unlocked and unattended. The findings included: The facility's Storage of Medications policy revised (MONTH) 2019 documented .drugs and biologicals .are stored in locked compartments .unlocked medication carts are not left unattended . Observations in the 500 Hall on 10/15/19 at 8:16 PM, the 500 Lower Hall Medication Cart was left unlocked and unattended. Interview with the Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked if medication carts are to be left unlocked. The DON stated, .no . | 2020-09-01 |
| 2402 | 2402 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 812 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by a dirty hand-washing sink in the Kitchen, dishwashing racks stored on the floor in the Kitchen, opened, unlabeled and undated foods stored in the Kitchen and in 1 of 3 (,[DATE] Hall Nourishment Room) nourishment rooms, wet towel on the floor in the Kitchen, a dirty steam table in the Kitchen, raw chicken and frozen foods left sitting at room temperature in the Kitchen, and foods on the floor in the Kitchen. The facility had a census of 98 residents, with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's FOOD STORAGE policy with a revision date of [DATE], documented, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label and date .Chicken should be stored on ice to maintain an optimal temperature .Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture .milk .should be stored .in refrigeration at 41 (degrees) F (Fahrenheit) or less .All foods should be stored .off the floor .Internal thermometers are to be in the warmest area of the refrigerator or freezer .Record temperatures from the internal thermometers .Employee food and resident food should not be stored together . 2. Observations in the Kitchen on [DATE] beginning at 8:45 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. Two dish racks on the floor in the dishware washer area. The Dietary Manager (DM) confirmed they were on the floor, and picked them up. c. A milk cooler filled with milk and no thermometer inside. The DM confirmed there were no thermometers in the milk cooler. The DM stated, M… | 2020-09-01 |
| 2403 | 2403 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 842 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Resident Assessment Instrument (RAI) Manual, policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to pressure ulcers for 1 of 4 (Resident #31) sampled residents reviewed for pressure ulcers and medication administration related to insulin and intravenous (IV) antibiotics for 2 of 6 (Resident #59 and #61) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the RAI Manual, (YEAR) Minimum Data Set (MDS) 3.0 Updates, revealed that when a resident who is admitted to the nursing home without a pressure ulcer develops a pressure ulcer in the nursing home, is admitted to the hospital for acute condition changes and then readmitted to the nursing home with the same pressure ulcer, that pressure ulcer is not considered present on admission but is a facility acquired pressure ulcer. Medical record review revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly Wound Assessment Report dated 3/27/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date Wound Identified .8/29/2017 .Present upon admission .No .Stage 4 . A weekly Wound Assessment Report dated 4/2/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date wound identified .4/2/19 .Present upon admission .Yes .Assessment Occasion .Re-assessment .Resident out of the facility From Date .3/28/2019 .Thru Date .4/2/2019 . All weekly Wound Assessment Reports from 4/2/19 through 10/15/19 documented, .Date wound identified .4/2/2019 .Present upon admission .Yes . Observations in Resident #31's room on 10/16/19 at 10:08 AM, revealed wound care was performed on Resident #31's Stage 4 coccyx pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 10/16/19 at 3:10 PM, in the 400 Hall Dining Area, LPN #1 was asked if Resident #31 had a stage 4 coccyx pressure ulcer when he went out to the … | 2020-09-01 |
| 2404 | 2404 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-10-17 | 880 | D | 0 | 1 | PSHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when isolation precautions were not followed for 1 of 2 (Resident #49) sampled residents reviewed and facility staff failed to protect resident's personal clothing from environmental contamination. The findings include: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) (YEAR) revealed .when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (The Centers for Disease Control) (CDC) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Pt (patient) to be in contact isolation r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in wound . Observations in the 500 Hall on 10/14/19 at 8:30 AM, revealed no isolation signs on Resident #49's door. Resident #49 had a roommate who was not in isolation. Observations in the 500 Hall on 10/14/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #7 donned gloves to enter Resident #49's room. LPN #7 confirmed that she wore gloves only because his wounds were contained and he was not contagious. Observations on 10/15/19 in the 500 hall revealed the following: a. Certified Nursing Assistant (CNA) #3 entered Resident #49's room at 8:00 AM to deliver the breakfast tray. CNA #3 did not wear gloves or any Personal Protective Equipment (PPE) when she entered the room. b. CNA #4 entered Resident #49's room at 5:… | 2020-09-01 |
| 2405 | 2405 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 584 | D | 0 | 1 | 38WC11 | Based on policy review, observation, and interview the facility failed to maintain a sanitary environment in 1 of 50 (Resident #21, 30, 48, and 66's shared bathroom) resident bathrooms. The findings include: 1. The facility's Cleaning and Disinfecting residents' Rooms policy with a revision date of 8/13 documented, .Housekeeping surfaces .will be cleaned on a regular basis .and when these surfaces are visibly soiled . 2. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 11:12 AM revealed bowel movement in the toilet, a brown substance smeared on the toilet seat, and crumpled used paper towels lying on top of the toilet tissue dispenser beside the toilet. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 2:39 PM and 4:35 PM revealed a brown substance smeared on the toilet seat and on top of the toilet tissue holder beside the toilet. Interview with Certified Nursing Assistant (CNA) #1 on 12/10/18 at 4:38 PM in Resident #21, 30, 48, and 66's shared bathroom, CNA #1 was asked who cleaned the bathrooms. CNA confirmed it was housekeeping staff. CNA #1 was asked how often they are cleaned. CNA #1 stated, They are here from 6 in the morning until .maybe 2. I don't see them after I come back from lunch. CNA #1 was asked if the smeared brown substance on the toilet seat and on the toilet tissue dispenser was acceptable. CNA #1 stated, No, not at all. CNA #1 was asked if the residents use that bathroom. CNA #1 stated, Yes, (Resident #30) does. Interview with the Director of Nursing (DON) on 12/12/18 at 2:27 PM in the conference room , the DON was asked how often he expected staff to make rounds in resident rooms and bathrooms. The DON stated, At least every 2 hours and PRN (as needed) . The DON was asked if it was acceptable for a resident bathroom to have unflushed bowel movement in the toilet, a brown substance smeared on the toilet seat and on the toilet paper dispenser in a resident's bathroom. The DON stated, No ma'am. | 2020-09-01 |
| 2406 | 2406 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 604 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure residents were free from physical restraints for 1 of 1 (Residents #77) resident reviewed for restraints. The findings include: The Physical Restraint Application policy dated (MONTH) 2010 documented, .Physical restraints are defined by Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily .The resident must be physically and cognitively able to self-release devices such as .seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment and no use of physical restraints. The Care Plan dated 11/8/18 documented, .May use seat belt on wheelchair for safety. Check every 30 min (minutes) and release every 2 hours . The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM, and on12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in her wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) in the conference room on 12/10/18 at 1:13 PM, the DON was asked about the seat belt. The DON stated, .She has had it for at least 3 years . Interview with Certified Nursing Assistant (CNA) #2 on 12/12/18 at 8:47 AM on the 400… | 2020-09-01 |
| 2407 | 2407 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 623 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to notify the Ombudsman of an emergency transfer for 1 of 4 (Resident #65) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].send to ER (emergency room ) . Review of the facility's Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #65 was not on the list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #65 was transferred to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 12/12/18 at 9:38 AM in the conference room, the DON confirmed Resident #65 was not on the (MONTH) Emergency Transfer form. | 2020-09-01 |
| 2408 | 2408 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 641 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for physical restraints for 1 of 18 (Resident #77) sampled residents reviewed. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADLs), and no use of physical restraints. The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM and on 12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) on 12/12/18 2:47 PM in the conference room, the DON was asked whether the seat belt and Pommel cushion should be coded as restraints on the MDS assessments. The DON stated, It is not coded as a restraint, because it is not a restraint. The facility was unable to provide documentation that a restraint assessment was performed to determine if the seat belt and pommel cushion were restraints. | 2020-09-01 |
| 2409 | 2409 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 656 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to follow care plan interventions related to pain assessments for 2 of 18 (Resident #40, and #64) sampled residents. The findings include: 1. The facility's Using the Care Plan policy documented, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .6. Documentation must be consistent with the resident's care plan . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The Care Plan dated 11/3/18 documented, .Evaluate pain at least Q (every) shift and PRN (as needed). Administer pain medication as needed and evaluate effectiveness. Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at the 100 hall nurse station, LPN #1 was asked if the Pain Assessments were completed for Resident #40. LPN #1 stated, We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON confirmed the pain assessments were not documented on the Medication Administration Record. The DON was asked if the pain assessments were documented for Resident #40 and if the care plan was being followed for Resident #40. The DON stated, No. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (restless leg syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on MAR (Medication Administration Record) . Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she … | 2020-09-01 |
| 2410 | 2410 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2018-12-12 | 697 | D | 0 | 1 | 38WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure pain assessments were completed according to the facility policy for 2 of 7 (Resident #40 and Resident#64) sampled residents reviewed for pain. The findings include: 1. The facility's Pain Assessment and Management policy with a revised date of (MONTH) (YEAR) documented, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Document the resident's reported level of pain .Upon completion of the pain assessment, the person shall record the information obtained from the assessment in the resident's medical record . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #40 was severely cognitively impaired, required extensive to total staff assistance for activities of daily living, and received scheduled pain medication or was offered as needed (PRN) pain medications. The Care Plan dated 11/3/18 documented, .at risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] and End Stage disease process .Resident will be kept comfortable while on hospice .Evaluate pain at least Q (every) shift and PRN. Administer pain medication as needed and evaluate effectiveness. The physician's orders [REDACTED].[MEDICATION NAME] HCL 50 MG (milligrams) TABLET GIVE 1/2 TABLET 25 MG BY MOUTH AS NEEDED EVERY 8 HOURS FOR PAIN .10/29/18 .[MEDICATION NAME] 300 MG CAPSULE BY MOUTH THREE TIMES DAILY . Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at 100 hall's nurses station, LPN #1 was asked if the Pai… | 2020-09-01 |
| 4152 | 4152 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 279 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a plan of care that identified the resident's dental status for 1 of 2 (Resident #22) sampled residents of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken .the care planning decision is marked yes .there should have been a care plan for dental. The facility was unable to provide a care plan for Resident #22's dental status. | 2019-11-01 |
| 4153 | 4153 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 332 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #1) staff nurses administered medications with a medication error rate of less than 5 Percent (%). A total of 5 medication errors were made out of 25 opportunities, resulting in a medication error rate of 20%. The findings included: The facility's Crushing Medications policy documented, .Crushed medications should be administered with .soft foods to ensure that the resident receives the entire dose ordered . Medical record reviewed revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].MAY CRUSH ALL CRUSHABLE MEDS (medications) MIXED IN PUDDING .[MEDICATION NAME] .0.75(milligrams) .STRESS B WITH ZINC TABLET GIVE 1 .[MEDICATION NAME] ([MEDICATION NAME]) 100 MG (MILLIGRAMS) CAPSULE .[MEDICATION NAME] .7.5 MG TABLET .[MEDICATION NAME] 100 MG 1 (TABLET) . Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 administered [MEDICATION NAME] 0.75 mg, Stress Formula with Zinc, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 100 mg crushed in a cup mixed with pudding. LPN#1 left pill fragments in the cup and on the spoon. Interview with the Director of Nursing (DON) on 11/16/16 at 11:35 AM, in the DON's office, the DON was asked if is it appropriate for any of the crushed medications to be left in the cup or on the spoon after medication administration. The DON stated, No. | 2019-11-01 |
| 4154 | 4154 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 371 | F | 0 | 1 | HQE411 | Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up on pans, the deep fryer, the flat grill, and the oven, and by dietary staff with exposed hair in the kitchen on 2 of 3 (11/14/16 and 11/15/16) days of the survey. The facility had a census of 89, with 86 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's POTS AND PANS - SANITIZING SOLUTION policy documented, .Pots and pans need to be free of black buildup deep scratches and dents . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up and grease on 6 sheet pans. Interview with the Dietary Manager (DM) on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon and grease build-up on sheet pans in the clean area. The DM stated No, it's not acceptable. 2. The facility's DEEP-FAT FRYER policy documented, .Turn off the heating element, drain, rinse with warm vinegar water then rinse thoroughly with clear hot water .wipe the fryer completely dry .Clean the outside of the fry kettle with grease solvent . The facility's OVEN - CONVENTIONAL, GAS policy documented, .remove spills, spillovers, and burned food deposits . The facility's GRILL - GAS policy documented, .Scrape grill to loose burned-on particles .Wash back and side guards with soap and water . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up on the deep fryer, the flat grill, and the oven. Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon build-up on kitchen equipment. The DM stated, No, it's not acceptable. 3. The facility's PERSONAL HYGIENE policy documented, .Wear .a hair restraint .Hair must be .completely covered . Observations in the kitchen on 11/14/16 and 11/15/16 revealed the following Dietary Staff (DS) with exposed hair: a. 11/14/… | 2019-11-01 |
| 4155 | 4155 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 412 | D | 0 | 1 | HQE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide dental services to meet the needs of 1 of 2 (Resident #22) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Marketing Director/Interim Social Worker (MDISW) on 11/16/16 at 7:51 AM, on the 300 hallway, the MDISW was asked if she had any information about Resident #22's broken and missing dentures. The MDISW stated, I have not heard of anything . Interview with the MDISW on 11/16/16 at 8:41 AM, in the conference room, the MDISW stated, I checked, and he is not on any (dental) list .MDS did not communicate it over, so that is why he was missed . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are… | 2019-11-01 |
| 4156 | 4156 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2016-11-16 | 441 | D | 0 | 1 | HQE411 | Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) staff nurses failed to clean a stethoscope before or after use, and failed to perform proper hand hygiene during medication administration. The findings included: Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 placed the stethoscope on the resident's skin to check placement of a percutaneous endoscopic gastrostomy (PEG) tube. LPN #1 failed to clean the stethoscope before and after medication administration through Resident #5's PEG tube. Observations in Residents #77's room on 11/15/16 beginning at 10:53 AM, revealed LPN #2 used gloved hands to administer nasal spray medication to Resident #77. LPN #2 then went back to the medication cart in the hall, picked up a pen, opened the Medication Administration Record (MAR) binder, and began writing, all while still wearing the contaminated gloves. Interview with the Director of Nursing (DON) on 11/16/15 at 11:35 AM, in the DON's office, the DON was asked whether she expected staff to clean the stethoscope before and after checking PEG tube placement. The DON stated, Yes. The DON was asked whether it was appropriate to walk out of the room, touch a pen and chart while still wearing gloves that were worn during nasal spray administration. The DON stated, No. | 2019-11-01 |
| 5673 | 5673 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2015-09-30 | 250 | E | 0 | 1 | DWQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of a job description, medical record review, and interview, the facility failed to ensure the Social Service Director (SSD) participated, reviewed and updated the plans of care during quarterly interdisciplinary care plan meetings for 13 of 17 (Residents #5, 7, 34, 36, 44, 58, 85, 88, 92, 93, 108, 109 and 118) sampled residents of the 27 residents included in the stage 2 review. The findings included: 1. The facility's Social Services Role and Policies policy documented, .Social services staff will participate as members of the interdisciplinary team (IDT), which reviews and plans the care of the resident . Social services will evaluate how the resident has adapted to the facility and whether there are any current personal needs. Social services will also determine whether there are any psychosocial adjustments or behavior problem . Social services will chart at least every 3 months. This documentation will include progress toward the care plan goals for identified psychosocial problems. Care plan approaches and problems will be re-evaluated at that time to ensure that they are working, and revisions will be done as needed . Duties include the following . 6. Participate as part of the interdisciplinary team in maintaining a plan of care . 2. The facility's SSD job description documented, .Participate in resident care planning by identifying the social and emotional needs of the residents in accordance with the medical assessment . Maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15, 5/14/15 and 8/5/15, revealed no documentation that the SSD participated in the quarterly care planning process t… | 2019-01-01 |
| 7335 | 7335 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2014-08-20 | 371 | D | 0 | 1 | ECQ511 | Based on policy review, review of the kitchen cleaning schedule, observation, and interview, it was determined the facility failed to maintain kitchen sanitation as evidenced by 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, sides and back splash of the fryer and a dark brown grease inside the fryer on 2 of 3 (8/18/14 and 8/19/14) days of the survey. The findings included: 1. Review of the facility's Dietary Department Guidelines policy documented, .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner . All areas of the dietary department will be cleaned on a regular schedule . 2. Review of the facility's kitchen cleaning schedule documented: .Sweep/mop under Everything . Each Shift . Deep Fryer . Daily . BEFORE LEAVING ON SUNDAY MAKE SURE THERE IS NOTHING ON THE FLOOR . 3. Observations in the kitchen on 8/18/14 at 9:38 AM, revealed 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer. 4. Observations in the kitchen on 8/19/14 at 11:05 AM, revealed the 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer was still present during the second day of the survey. 5. During an interview in the kitchen on 8/19/14 at 11:05 AM, the Dietary Manager was asked should the area around the fryer be clean. The Dietary Manager stated, Yes. | 2018-02-01 |
| 9365 | 9365 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 278 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for hospice care, pressure sores and/or falls 2 of 35 (Residents #20 and 53) sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].D/C (discharge) from Skilled Services to Hospice on 2/24/13 Hx (history) Dx (diagnosis) Lung CA (cancer) . Review of a significant change MDS dated [DATE] documented, .Section O . Special Treatments, Procedures, and Programs . Check all of the following treatments, procedures, and programs that were performed during the last 14 days . K. Hospice care . The box for hospice care was not checked. During an interview at the skilled nurses' station on 5/21/13 at 2:30 PM, Nurse #3 was asked to find the current order for hospice care for Resident #20. Nurse #3 stated, Here it is written on 2/22/13 . During an interview in the MDS office on 5/22/13 at 8:00 AM, MDS Nurse #2 stated, .we have to do a sig (significant) change on them when they go into hospice . MDS Nurse #1 was asked if the MDS was coded for hospice. MDS Nurse #1 stated to MDS nurse #2, .no you forgot to mark it . 2. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #53's nurses' notes dated 2/20/13 documented a 4:30 PM admission note that included, .also noted to inner buttocks 1.3 cm (centimeters) X (by) 0.3 cm open area . Review of the admission MDS assessment, dated 2/27/13 documented, .M0210. Unhealed Pressure Ulcer(s) . Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher . This pressure sore question was coded with a 0, indicating No. During an interview at the 500 hallway nurse's station on 5/21/13 at 8:10 AM, Nurse #2 stated Resident #53 was admit… | 2017-01-01 |
| 9366 | 9366 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 279 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to have a care plan for vision for 1 of 35 (Resident #62) sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] and 10/26/12 documented, Section B - Hearing, Speech, Vision . B0100 impaired - see large print but not regular print . Review of care plan dated 10/19/12 did not included care for vision. Observations in Resident #62's room on 5/21/13 at 8:00 AM, revealed Resident #62 sitting on side of bed working a puzzle using a magnifying glass. During an interview in Resident' #62's room on 5/22/13 at 7:45 AM, Resident #62 stated, I picked out me some frames for some glasses last week . I can't wait till (until) they (glasses) get here . During an interview in the MDS office on 5/22/13 on 9:00 AM, MDS Nurse #1 was asked should vision be care planned. MDS Nurse #1 stated, .vision should be in the care plan and it is not there . | 2017-01-01 |
| 9367 | 9367 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 309 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure physician orders [REDACTED].#125) sampled residents included in the stage 2 review. The findings included: Review of the facility's Lab (laboratory) and Diagnostic Test Results-Clinical Protocol policy documented, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs . Medical record review for Resident #125 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the original physician's orders [REDACTED].#125 documented, .LAB ORDERS . CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) EVERY 6 MONTHS . The facility was unable to provide results of the CBC and BMP that were due in 3/13. During an interview in the conference room on 5/22/13 at 10:50 AM, the Director of Nursing (DON) was asked for the results of the CBC and BMP that was due in 3/13. The DON stated, .it's (3/13 lab work) not there . it wasn't done . | 2017-01-01 |
| 9368 | 9368 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-05-22 | 314 | D | 0 | 1 | PLOD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure pressure sore treatments were done for 1 of 2 (Resident #67) sampled residents reviewed with pressure ulcer of the 35 residents included in the stage 2 review. The findings included: Review of the facility's treatment of [REDACTED]. Responsibilities of team members include . Documentation . Medical record review for Resident #67 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Telephone Orders dated 5/3/13 documented, .Apply . Zinc Vaseline 1: (to) 1:1 comp (composition) to sacral area BID (two times a day) & (and) PRN (as needed) till (until) resolved . Review of the treatment record dated 5/3/13 through 5/31/13 revealed there was no pressure sore treatment documented for 5/15/13 and 5/16/13 on the 6:00 PM to 6:00 AM shift. Review of the Minimum Data Set ((MDS) dated [DATE] documented, .Section M Skin Conditions . M0700. Most Severe Tissue Type for Any Pressure Ulcer . 2. Granulation tissue . Observations in Resident #67's room on 5/21/13 at 3:30 PM, revealed Resident #67 with a stage 2 pressure sore on the sacrum area. During an interview in 400 hall nurses' station on 5/21/13 at 2:00 PM, Nurse #1 was asked should pressure sore treatments be documented. Nurse #1 stated, Yes . it (pressure sore treatments) should be documented on the treatment record . During an interview in 400 hall nurses' station on 5/21/13 at 3:00 PM, Nurse #2 was asked should pressure sore treatments be documented. Nurse #2 stated, .when treatments are done they should be documented on the treatment record . Nurse #2 was asked to verify the missing documentation for the pressure sore treatment on the treatment record for 5/15/13 and 5/16/13. Nurse #2 stated, .if (treatments were) done, it was not documented . | 2017-01-01 |
| 10878 | 10878 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 309 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to administer intravenous (IV) medications according to physician's orders [REDACTED].#6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligrams) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. A telephone order dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Review of the department notes revealed the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . b. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . c. 3/23/13 at 2:40 PM - Asked by Hall 3 nurse to attempt IV access d/t (due to) resident has orders for Meropenem 500mg IV every 12 hours until 3/25/13. Assessed resident for peripheral IV access. BUE (bilateral upper extremities) noted to be swollen and large. Multiple area of bruising noted and mulitpe (multiple) old IV sites noted. Did not attempt peripheral IV access. There was no documentation on 3/24/13 of attempts to start the IV to administer Meropenem 500 mg IV and no documentation of attempts to notify the physician of resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the ph… | 2016-04-01 |
| 10879 | 10879 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2013-04-30 | 514 | D | 1 | 0 | SKV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to maintain complete an accurate medical records for 1 of 6 (Resident #6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligram) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. Review of the department notes documented the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . Review of the Telephone Orders dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Further review of the department notes documented the following: a. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . b. 3/23/13 at 2:40 PM - old IV sites noted. Did not attempt peripheral IV access . There was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem does not come in an IM administration route. The DON stated, They (nurses) called the on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . The DON also confi… | 2016-04-01 |
| 12070 | 12070 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 279 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to develop an interim care plan in the first 24 hours of admission for 4 of 20 (Residents #4, 8, 11 and 12) sampled residents. The findings included: 1. Review of the facility's Care Plans----Preliminary policy documented, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission. 2. Medical record review for Resident #4 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. The first documented care plan for Resident #4 was dated 12/28/11. 3. Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 4. Medical record review for Resident #11 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide a dated interim care plan for the readmission date of [DATE]. 5. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 6. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when should a care plan be initiated. The DON stated, .within the first 24 hours of admission. | 2015-10-01 |
| 12071 | 12071 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 280 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the current status of a resident with pressure ulcers for 1 of 20 (Resident #8) sampled residents. The findings included: Review of the facility's care plan policy documented, .plan of care. shall be developed. To assure that the resident's immediate care needs are met. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 7/18/11 had no documented interventions for the [DIAGNOSES REDACTED]. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when the care plan should be initiated. The DON stated, .within the first 24 hours. | 2015-10-01 |
| 12072 | 12072 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 282 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow the care plan for turning, repositioning and skin care for 1 of 17 (Resident #8) sampled residents. The findings included: Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/29/11 documented, .Prone to skin breakdown. turn every 2 hours while in bed. Resident #8's medical record contained documentation of a hospitalized from [DATE] through 7/18/11 with a [DIAGNOSES REDACTED]. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the Director of Nursing (DON) was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours. | 2015-10-01 |
| 12073 | 12073 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 309 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for constipation for 4 of 20 (Residents #3, 11, 15 and 16) sampled residents. The findings included: 1. Review of the facility's Tri-County Healthcare Standing Physician Orders documented, .3. Stool Softener/Laxative: PRN (as needed) Constipation. a. [MEDICATION NAME] S: 1 pill at HS (hour of sleep) prn. b. MOM (milk of magnesia) 30 ml (milliliters) prn. c. [MEDICATION NAME]: 2 tabs (tablet) prn. d. [MEDICATION NAME] tabs: 2 at HS prn. e. [MEDICATION NAME] Suppository 1 PR (per rectum) prn. f. Check for impaction prn and remove if indicated. 4. Enema of choice prn: Severe constipation. 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's BM (bowel movement) Detail option 2 Roster had no BM documented from 10/18/11 through (-) 10/25/11 and from 11/27/11 - 12/1/11. The Medication Administration Record [REDACTED]. The facility failed to implement the physician's standing orders for constipation. 3. Medical record review for Resident #11 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #11's BM Detail option 2 Roster had no BM documented from 2/1/11 - 12/8/11, 1/8/12 - 1/12/12, 1/13/12 - 1/23/12, 1/23/12 - 2/2/12 and 2/12/12 - 2/18/12. The MAR indicated [REDACTED]. 4. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #15's BM - Yes/No (Only) Roster had no BM documented from 2/5/12 - 2/9/12. The facility failed to implement the physician's standing orders for constipation. During an interview in the conference room on 2/23/12 at 10:50 AM, the Director of Nursing (DON) was asked to review Resident #15's bowel movement record. The DON stated, .He (Resident #15) should have received something (for lack of a BM). Expect the nurse to revie… | 2015-10-01 |
| 12074 | 12074 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 314 | D | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Clinical Practice Guidelines, policy review, medical record review and interview, it was determined the facility failed to follow the care plan intervention to turn every two hours to prevent the development of a pressure ulcer for 1 of 3 (Resident #8) sampled residents with pressure ulcers. The findings included: Review of the NPUAP Clinical Practice Guidelines documented, .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours. A written schedule for systematically turning and repositioning the individual should be used. Review of the facility's Skin Program Policy documented, .The nursing department coordinates the response to patient needs.with an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. Medical record review for Resident #8 documented an admission date of [DATE] with readmitted s of 7/18/11 and 8/19/11 and [DIAGNOSES REDACTED]. Review of the care plan documented an approach dated 6/17/11 for Staff to turn and repo (reposition) res (resident) q2hrs (every two hours) and prn (as needed). Review of Weekly Skin Integrity Assessment dated 7/9/11 documented, .Skin Condition Dry. Skin Intact. Review of a nurse's note dated 7/10/2011 documented, .reddened area to buttocks with bluish and blackened areas, with blisters. 2 small opened areas. Review of a nurse's note dated 7/11/2011 documented, .no change to residents buttocks, blistered area still dark discoloration, serosanguenous drainage present. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the DON was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we… | 2015-10-01 |
| 12075 | 12075 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2012-02-23 | 441 | E | 0 | 1 | 40S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Association for Professionals in Infection Control and Epidemiology (APIC) Guide to the Elimination of Clostridium difficile in Healthcare Settings, policy review, medical record review, cleaning product efficacy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by utilizing an ineffective cleaning product for 4 of 4 (Residents #8, 14, 19 and 20) sampled residents with Clostridium difficile infection. It was also determined the facility failed to ensure practices to prevent the potential spread of infection when staff members failed to practice sanitary hand hygiene during 1 of 2 dining observations and during catheter care for sampled Resident #6. The findings included: 1. Review of the APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings documented, .Disinfectants commonly used in healthcare settings include quaternary ammoniums and [MEDICATION NAME], neither of which are sporicidal. only chlorine-based disinfectants. kill spores. Review of the facility's Cleaning, Disinfection and Sterilization policy documented, .provide supplies and equipment that are adequately cleaned, disinfected or sterilized. a. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff (Clostridium difficile - an intestinal bacteria which has spores that can live on inanimate objects, such as beds and overbed tables, for up to six months). b. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff. c. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a discharge summary dated 2/23/11 documented, .resident developed [DIAGNOSES REDACTED] at (name of local hospital) .a… | 2015-10-01 |
| 13806 | 13806 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 332 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations and interviews, it was determined the facility failed to ensure 3 of 6 (Nurses #3, 5 and 6) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 5 errors were observed out of 40 opportunities, resulting in a medication error rate of 12.5%. The findings included: 1. Review of the facility's "Administering Medications through a Metered Dose Inhaler" policy documented, "...Allow at least one (1) minute between inhalations of the same medication..." Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 11/29/10 at 11:45 AM, revealed Nurse #3 administered two puffs of a [MEDICATION NAME] inhaler to RR #1. Nurse #3 did not pause between the puffs. Failure to pause at least one minute between the puffs resulted in medication error #1. 2. Medical record review for Resident #6 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #6's room on 11/30/10 at 6:25 AM, revealed Nurse #6 administered one eye into each of Resident #6's eyes. Failure to administer two eye drops into each eye resulted in medication error #2. During an interview on side three on 11/30/10 at 8:20 AM, Nurse #6 stated, "You're right I should have given two drops and I only gave one." 3. Review of the facility's "Insulin Administration" policy documented, "...8. Check the order for the amount of insulin..." Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #16's room on 11/30/10 at 7:15 AM, Nurse #6 performed a fingerstick blood sugar (FSBS) on Resident #16's with results of 12… | 2014-09-01 |
| 13807 | 13807 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 465 | E | 0 | 1 | IDW711 | Based on observations and interviews, it was determined the facility failed to ensure the environment was clean and sanitary as evidenced by a soiled shower chair, a dark brown buildup on the tile, and feces on the drain in the shower stall in 2 of 2 (Shower rooms 1 and 2) shower rooms. The findings included: 1. Observations in Shower #2 on 11/29/10 at 9:35 AM and 3:25 PM and on 11/30/10 at 3:15 PM, revealed a clump of dark brown substance on the drain in the shower stall and a dark brown buildup covering the tile near the drain. During an interview in Shower #2 on 11/30/10 at 3:15 PM, Housekeeper #1 was asked what the dark brown buildup on the tile was and what was the brown substance on the drain. Housekeeper #1 stated, "I don't know what that is on the tile. It has been there for awhile. That's BM (bowel movement) on the drain." 2. Observations in Shower #1 on 11/29/10 at 3:35 PM and on 11/30/10 at 3:15 PM, revealed a bariatric shower chair in the shower stall with the safety belts soiled with brown stains. During an interview in Shower #1 on 11/30/10 at 3:15 PM, the Housekeeping Supervisor was asked if the shower chair was clean. The Housekeeping Supervisor stated, "No and I wouldn't want that belt around me. It's dirty." | 2014-09-01 |
| 13808 | 13808 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 334 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to provide the influenza vaccine for 1 of 22 (Resident #7) sampled residents. The findings included: Review of the facility's "Vaccination of Residents" policy documented, "...Influenza Vaccination... all residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident has already been vaccinated..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 10/7/10 documented, "...Flu vac (vaccine) 0.5 ml (milliliters)..." The facility was unable to provide documentation that the flu vaccine had been administered to Resident #7. During an interview at the side 3 nurse's station on 11/29/10 at 2:40 PM, Nurse #8 was asked if Resident #7 received the flu vaccine. Nurse #8 reviewed the medical record and stated, "...It should have been documented on the MAR (medication administration record), nurse's notes, and care plan. I don't see that. I'm not sure that she got it." | 2014-09-01 |
| 13809 | 13809 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 431 | D | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure a medication cart was locked and medications were not left unattended in 1 of 8 (Side 2 medication cart) medication storage areas. The findings Included: Review of the facility's "Storage of Medications" policy documented, "...The facility shall store all drugs and biological in a safe, secure, and orderly manner... Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others..." Observations on side 2 on 11/30/10 at 7:00 AM, revealed the side 2 medication cart was left unattended, unlocked and out of view of the nurse. Observations on side 2 on 11/30/10 at 7:31 AM, revealed a vial of Novolin 70/30 insulin was sitting on top of side 2's medication cart unattended. During an interview on side 2 on 11/30/10 at 7:10 AM, the surveyor told Nurse #6 that she had left the side 2 medication cart unlocked. Nurse #6 stated, "I know it's a bad habit, when I just step right in there (referring to resident's room) I forget." During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nursing stated, "Med (medication) cart should always be locked." | 2014-09-01 |
| 13810 | 13810 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 282 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interviews, it was determined the facility failed to follow interventions on the care plan for floor mats and a pressure relief mattress for 1 of 22 (Residents #5) sampled residents. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 1/27/10 documented, "...pressure relief mattress for comfort and prevention..." and dated 2/25/10 documented, "...low bed with mats in place..." Observations in Resident's #5's room on 11/29/10 at 4:00 PM and on 11/30/10 at 8:30 AM,10:05 AM, 12:05 PM and 2:20 PM, revealed there were no floor mats and a pressure relief mattress in place for Resident #5. During an interview in Resident #5's room on 11/30/10 at 2:40 PM, Nurse #7 verified there were no floor mats or a pressure relief mattress present. During an interview at side 1 nurses' station on 11/30/10 at 2:45 PM, the Director of Nursing confirmed that floor mats and pressure relief mattress were on the care plan but were not implemented for Resident #5. | 2014-09-01 |
| 13811 | 13811 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 309 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to follow physician orders [REDACTED].#17 and 19) sampled residents. The findings included: 1. Medical record review for Resident #17 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered 18 AND CALL MD (Medical Doctor) IF NO RESULTS..." Review of the July 2010 diabetic record for Resident #17 revealed the following BS's above 300 that were not rechecked to determine the results of the insulin administered: a. 7/10/10-4:30 PM, BS-354. b. 7/15/10-4:30 PM, BS-314. c. 7/15/10-8:00 PM, BS-338. d. 7/17/10-11:30 AM, BS-321. e. 7/17/10-8:00 PM, BS-314. f. 7/21/10-11:30 AM, BS-311. g. 7/21/10-8:00 PM, BS-397. h. 7/22/10-11:30 AM, BS-307. i. 7/23/10-4:30 PM, BS-400. j. 7/23/10-8:00 PM, BS-381. k. 7/26/10-8:00 PM, BS-328. l. 7/28/10-4:30 PM, BS-310. m. 7/29/10-7:30 AM, BS-305. n. 7/29/10-8:00 PM, BS-380. o. 7/30/10-8:00 PM, BS-318. During an interview in the conference room on 12/1/10 at 10:45 AM, Nurse #8 stated, "They need to recheck it (BS) to see if the BS has gone down, that's the only way to know the results. Usually recheck it in 45 minutes to an hour unless the doctor has a specific order." 2. Medical record review for Resident #19 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 10/4/10 documented, "...Give Nov ([MEDICATION NAME]) R 15 u now Recheck in 2 hrs (hours) for BS 442..." The physician's orders [REDACTED]." Review of the October 2010 medication administration record (MAR) for Resident #19 documented the following BS results: a. 10/4/10 8 PM BS 441. b. 10/15/10 5:30 PM BS 433. The facility was unable to provide documentation of rechecks in 2 hrs of a BS over 400. Further medical record review revealed a physician's telephone order dated 10/4/… | 2014-09-01 |
| 13812 | 13812 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 280 | D | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interviews, it was determined the facility failed to revise the comprehensive care plan for care of emergency bleeding for 2 of 22 (Resident #18 and 19) sampled residents. The findings included: 1. Review of the facility's "[MEDICAL TREATMENT], [MEDICAL TREATMENT]" policy documented, "...Check graft site for bleeding upon return post-[MEDICAL TREATMENT] and per MD (Medical Doctor) orders. If bleeding occurs, apply direct pressure until controlled. Notify MD and DON (Director of Nursing) if bleeding lasts longer than 30 minutes or is severe initiate EMS (Emergency Management Service) system." 2. Medical record review for Resident #18 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/26/10 documented "[MEDICAL TREATMENT] as ordered. Assess site... q (every) d (day) for s/s (signs and symptoms) inf. (infection) or bleeding assess for thrill/bruit q shift..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 3 nurses' station on 12/1/10 at 1:00 PM, Nurse #9 stated, "(Care plan) says to check for it (emergency bleeding) but doesn't really say what to do for it." 3. Medical record review for Resident #19 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/23/10 documented "...Check shunt or port site for s/s of infections, pain or bleeding daily and PRN (as needed)..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 1 nurses' station on 12/1/10 at 1:52 PM, the DON stated, "It (care plan) should have interventions for a bleed but it wasn't included." | 2014-09-01 |
| 13813 | 13813 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 441 | E | 0 | 1 | IDW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, observations, and interviews, it was determined 5 of 24 staff members (Certified Nursing Assistants (CNA) #1, CNA #2, Rehabilitation Coordinator, Dietary Manager and Nurse #2) failed to ensure infection control practices were used to prevent the potential spread of infection by not using sanitary hand hygiene or touching food and straws with their bare hands. Two (2) of 6 nurses (Nurses #5 and #6) failed to clean the glucometer with a Super Sani-wipe. The findings included: 1. Review of the facility's "Hand-hygiene" policy documented, "...2. hand washing ...b. after contact ...with non-intact skin... d. before and after eating or handling food... 3. a. before or after direct contact with residents... g. after contact with resident's intact skin... i. after contact with inanimate objects (...equipment) in the immediate vicinity of the resident..." a. Observations in room [ROOM NUMBER] A on 11/30/10 at 7:45 AM, CNA #1 held the toast with his bare hand to put jelly and butter on it. Observations in room [ROOM NUMBER] A on 11/30/10 at 12:15 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands. Observations in room [ROOM NUMBER] B on 11/30/10 at 12:20 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands, opened the straw and touched the straw with her bare hand. b. Observations in room [ROOM NUMBER] on 11/30/10 at 7:18 AM, CNA #2 repositioned a resident, adjusted the bed with the bed control and moved a box under the bed and then began to set up the tray opening the butter and the sweetner. CNA #2 then began to fed the resident. CNA #2 did not wash her hands prior to tray set up or before she fed the resident. Observations in room [ROOM NUMBER] on 11/30/10 at 7:40 AM, CNA #2 did not wash her hands prior to delivery of the meal tray or prior to opening the milk and butter. CNA #2 left the room and proceeded to get the next tray without washing hands. Observations in room [ROOM NUMBER]… | 2014-09-01 |
| 13814 | 13814 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2010-12-01 | 371 | E | 0 | 1 | IDW711 | Based on policy review, observations, and interviews, it was determined the facility failed to ensure that staff had hair and beards covered in the kitchen on 2 of 3 (11/29/10 and 12/1/10) days and that dishes were air dried on 1 of 3 (11/29/10) days of kitchen observations. The findings included: 1. Review of the facility's "DRESS CODE" policy documented, "...B. Dietary staff ...Hair Nets..." Observations in the kitchen on 11/29/10 at 9:00 AM and 1:55 PM, revealed dietary staff #1 working at the ware washer and on the tray line. Dietary staff member #1's beard was not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #1 was working on the tray line with his beard not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #3 stocking supplies in the kitchen. Dietary staff member #3 was wearing a cap that partially covered his hair and his beard was not covered. Observations in the kitchen on 12/1/10 at 8:15 AM, revealed dietary staff members #1 and #3 were in the kitchen with no beard coverings on and dietary staff member #3's hair was partially uncovered. During an interview in the kitchen on 12/1/10 at 8:15 AM, the Dietary Manager (DM) was asked about hair coverings. The dietary manager stated, "They (staff members) wear caps but no beard covers. I don't think our policy says anything about beard covers." The dietary manager agreed that the facial hair was not covered. 2. Review of the facility's "Departmental Policies" documented, "...All pots and pans must be air dried after the final sanitizing rinse..." Observations in the kitchen on 11/29/10 at 9:00 AM, revealed dietary staff member #1 was removing clean dishes from the ware washer and drying the dishes with a towel. Observations in the kitchen on 11/29/10 at 1:55 PM, revealed dietary staff member #2 was removing clean dishes from the ware washer and drying the dishes with a towel. During an interview in the dietary office on 12/1/10 at 8:10 AM, the DM was asked about drying the dis… | 2014-09-01 |
| 659 | 659 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-03-14 | 565 | E | 1 | 0 | 2X2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Resident Council Meeting Minutes, medical record review, observations, and interviews the facility failed to ensure the residents' concerns/grievances related to staffing and call light response time were promptly acted upon for residents who attended resident council meetings, and for two (Resident #5 and #13) of six residents (Residents #1, #3, #5, #9, #12, and #13) sampled for quality of care. The findings included: Review of the resident Council Meeting Minutes for the past six months (October (YEAR) - (MONTH) (YEAR)) revealed the following: On 10/4/17 one resident stated he was not being changed at night on the second to third shift. He stated the facility needed more nurses and aides. On 11/1/17 one resident stated he was not being changed at night on the third shift. The minutes indicated, Multiple residents at the meeting complained of late night/early morning staff not answering call lights. On 12/6/17 one resident stated he was still not being changed on the second and third shift. The minutes indicated, Residents stated some staff just walks in the room and turns call light off and walks out without asking what they need. On 1/3/18 the minutes indicated, Residents stated call lights were still being turned off at times without finding out what the problem is. They also stated that if the call lights were answered it took a while to be answered. One resident stated if the call light was answered, some staff said they would be back, but did not come back or came back 1 to 2 hours later. On 2/7/18 the residents stated they felt the call lights could be answered timelier on the first and third shifts. On 3/7/18 one resident stated her call light was not being answered timely and one resident stated he was not being changed. Continued review revealed none of the Resident Council Meeting minutes included documentation of previous concerns raised by the group and what action had been taken to resolve them. Observa… | 2020-09-01 |
| 660 | 660 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-03-14 | 600 | D | 1 | 0 | 2X2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revea… | 2020-09-01 |
| 661 | 661 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-03-14 | 725 | E | 1 | 0 | 2X2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she need… | 2020-09-01 |
| 662 | 662 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2019-03-26 | 550 | D | 0 | 1 | GERH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to promote resident rights to respect and dignity, and ensure privacy for 1 resident (#8) of 1 resident reviewed of 19 sampled residents. The findings include: Review of the facility policy Dignity and Respect, dated 7/91, revealed .Residents' individual preferences .clothing .are elicited and respected by the facility .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by . Review of the facility policy Activities of Daily Living, dated 3/17, revealed .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. Further review revealed dressing required extensive assistance of 2 staff members. Medical record review of Resident #8's care plan, dated 12/26/18, revealed .Assist me with bed mobility, transfers, toileting, grooming, dressing, and locomotion . Observation and family interview with Resident #8's family on 3/24/19 at 12:45 PM, in the resident's room, revealed the resident was .left in hospital clothes, and never has pants on . The resident was dressed in a hospital gown, without pants, at the time of the interview. Observation and family interview with Resident #8's family on 3/25/19 at 4:57 PM, in the resident's room, revealed the resident remains in bed dressed in a hospital gown, and no pants.I wish they would put clothes on him every day .it would make him feel better, and stay warmer . Observation of Resi… | 2020-09-01 |
| 663 | 663 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2019-03-26 | 812 | F | 0 | 1 | GERH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to discard expired and damaged food items and failed to ensure food items were not open to air in 2 of 3 coolers, 1 of 1 bread racks, and 1 of 1 freezers. The findings include: Review of the facility policy Food Storage dated [DATE], revealed .Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines . Observation of the kitchen with Dietary Aide #1 on [DATE] at 9:43 AM, revealed the following: In the upright cooler: (5) cartons of 2% (percent) milk with a use by date of [DATE] In the milk cooler: (13) cartons of 2% (percent) milk with a use by date of [DATE] On the bread rack: (3) packages of 12 count hotdog buns with a use by date [DATE] (6) 1lb (pound) loaves of whole wheat bread with a use by date of [DATE] (2) 1lb loaves of sandwich bread with a use by date of [DATE] (1) 1lb sandwich bread with the bread damaged and open to air with a hole in the bottom of the bag (5) slices left in a 1lb bag of wheat bread with a use by date of [DATE] In the walk-in freezer: (2) frozen burger patties in a box open to air (1) 20 lb box of frozen peas open to air (20) frozen biscuits in a box open to air Interview with the Dietary Director on [DATE] at 10:30 AM, in the kitchen, confirmed the facility failed to ensure expired food items were not available for resident use, failed to ensure damaged foods were not available for resident use, and failed to ensure foods were not stored open to air. | 2020-09-01 |
| 664 | 664 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-05-02 | 657 | D | 0 | 1 | Y2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to revise the care plan for 1 resident (#71) of 18 sampled residents. The findings included: Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet Review of facility's Incident Case Report dated 4/10/18 with completion date of 5/1/18 revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bed pan. Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Review of Resident #71's current KARDEX revealed, no intervention for use of bedpan , further review revealed, .Fall interventions: Non-skid socks. Interview with CNA # 1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 used bedside commode (BSC) for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #71 following a fall. | 2020-09-01 |
| 665 | 665 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-05-02 | 689 | D | 0 | 1 | Y2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility investigation, medical record review, observation, and interview, the facility failed to implement a new intervention and monitor effectiveness of interventions after a fall for 1 resident (#71) of 4 residents reviewed for falls of 18 sampled residents. The findings included: Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet For 72 hours following the fall, staff will document .The resident's reaction/response to the new fall intervention placed . Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required staff assistance for transfers and toileting. Medical Record Review of progress notes dated 4/14/18 revealed, This nurse was approached by CNA and told that resident had fallen in the floor . Review of facility's Incident Case Report dated 4/10/18 (correct date 4/14/18) revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bedpan. Review of Resident #71's current KARDEX (not dated) revealed no intervention for the use of a bedpan. Further review revealed, .Fall interventions: Non-skid socks . Observation of Resident # 71 on 5/01/18 at 7:56 AM, in the resident's r… | 2020-09-01 |
| 666 | 666 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-05-02 | 791 | D | 0 | 1 | Y2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to ensure dental services were provided for 1 resident (#17) of 18 sampled residents. The findings included: Review of the facility policy Dental Services - Professional, revised 3/17 revealed, .routine and emergency dental services are available to meet the resident's oral health .nursing services is responsible for notifying Social Services of a resident's need for dental services .Social Services personnel will be responsible for assisting the resident/family in making dental appointments . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed .Obvious or likely cavity or broken natural teeth . Observation of Resident #17 on 4/30/18 at 10:34 AM, in the resident's room revealed the resident with tooth decay. Interview with the Director of Social Services on 5/2/18 at 8:20 AM, in the Social Services Office, confirmed Resident #17 had tooth decay and was scheduled to be seen by dental services on 4/20/18. Further interview confirmed Resident #17 was not seen by dental services on 4/20/18 despite being scheduled. Continued interview confirmed the facility failed to provide dental services for Resident #17 since admission to the facility on [DATE]. | 2020-09-01 |
| 667 | 667 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2018-05-02 | 880 | D | 0 | 1 | Y2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#328) of 3 residents on isolation precautions of 18 residents sampled of 73 total residents. The findings included: Review of the facility policy Reverse Isolation revised 11/17 revealed, .Place 'Please see nurse before entering room' sign on the outer door . Medical record review revealed Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order dated 4/25/18 revealed, .reverse isolation (isolation procedures designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors) for [DIAGNOSES REDACTED] (an abnormally low count of a type of white blood cell) . Medical record review of the care plan dated 4/25/18 revealed, .I am in reverse isolation because my immune system is low and I am susceptible to bacteria/viruses .Post signs at my door informing visitors to check in with licensed staff prior to entering room . Observation during initial tour of Resident #328's room, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed no isolation precaution sign on the door. Interview with Certified Nurses Aid (CNA) #2, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed Resident #328 was on reverse isolation precautions and a mask needed to be worn when entering the resident's room for his protection. Interview with the Registered Nurse Consultant, on 4/30/18 at 10:06 AM, in the Station 3 hallway, confirmed Resident #328 was on reverse isolation precautions and the facilty failed to post a sign on the resident's door to notify staff and visitors of the reverse isolation. | 2020-09-01 |
| 4010 | 4010 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2016-12-22 | 204 | D | 1 | 0 | C3FJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 15 on a scale of zero-to-15, with 15 being the highest score achievable to indicate an intact cognition. Continued review revealed the Resident required limited assistance with all Activities of Daily Living (ADLs) except eating and bathing; and Resident #1 was independent with eating and required extensive assistance with bathing. Further review of the MDS Assessment revealed the discharge from the facility was planned. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review revealed no documentation a home health provider was notified to arrange skilled nursing services, prior to, or on the day of, the Resident's discharge on 10/31/2016. Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health) . Interview with the DSS on 12/14/2016 at 4:26 PM, in the Conference Room, revealed the DSS… | 2019-11-01 |
| 4011 | 4011 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2016-12-22 | 309 | D | 1 | 0 | C3FJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services and an antibiotic was not administered as ordered for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Summary and Skilled-Long Term Care Orders dated 10/26/2016 revealed Resident #1 was admitted to the hospital on [DATE] with [MEDICAL CONDITION] secondary to her right lower extremity wounds. Intravenous (IV) antibiotics were started on 10/22/2016 and administered through a Midline IV Catheter. Infectious Disease (ID) was involved in Resident #1's care due to the resistant bacteria in her leg wound and recommended treatment with [MEDICATION NAME] for a period of two weeks. Continued review revealed, Resident #1 received the 10/26/2016 dose of [MEDICATION NAME] prior to discharge. Further review revealed, upon discharge from the hospital to the facility, Resident #1 needed an additional 10 days of [MEDICATION NAME]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge from the facility was planned. Medical record review of a Physician's Telephone Order dated 10/26/2016 revealed an order for [REDACTED]. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review of an Interdisciplinary Progress Not… | 2019-11-01 |
| 6643 | 6643 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2015-01-14 | 224 | G | 0 | 1 | WY5111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Discharge Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident had moderately impaired cognitive skills for daily decision making. Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed .Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement) .When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person… | 2018-05-01 |
| 6644 | 6644 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2015-01-14 | 226 | G | 0 | 1 | WY5111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to investigate an injury of unkown origin for one resident (#11) and failed to follow the abuse policy for one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in physical harm to resident #11 and psychological harm to resident #87. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had [MEDICAL CONDITION] Disease and contractures to all four extremities. Medical record review of a nurse's note dated October 7, 2014, at 5:00 p.m., revealed .R (right) ext (extremity) swollen upper knee swollen .upon palpation to right extremity resident with moaning and facial grimacing-NP (nurse practitioner) notified-NO (new order) .to obtain X-Ray (R) knee and (R) femur . Medical record review of a Radiology Interpretation dated October 7, 2014, revealed .Right Hip .findings: a comminuted fracture (a fracture in which the bone is broken in several places or is shattered, creating numerous fragments) is present in the femoral neck and intratrochanteric region .There is a displacement of the greater trochanter . Review of an Orthopedic consult dated October 7, 2014, revealed, .nursing home resident with (R) intertrochanteric [MEDICAL CONDITION]. non-ambulatory previously. She does have bilateral lower and upper extremity contractures .unsure of mechanism of injury . Interview on January 13, 2015, at 2:48 p.m., with Licensed practical nurse (LPN) #3, in the conference room, revealed the LPN was notified of the change in resident condition by the resident's son at 5:00 p.m., on October 7, 2014. Continued interview revealed the LPN did not notice any changes on the prior assessments completed at 10:00 a.m., and 2:00 p.m. Interview and medical record review with the facility Medical Director on Ja… | 2018-05-01 |
| 6645 | 6645 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2015-01-14 | 282 | G | 0 | 1 | WY5111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the care plan for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in physical harm to resident #11. The findings included: Resident #11 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 was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, .Problem .(resident) continues to be at risk for falls d/t (due to) poor safety awareness .Goal .decrease risk for falls related injuries .transfer and mobility with 2 staff . Medical record review of a Status Change dated October 4, 2014, revealed .called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath .head called 911 . Medical record review of a Physician telephone order dated October 4, 2014, revealed .Send to .(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration . Medical record review of a hospital emergency report dated October 4, 2014, revealed, .mechanism of injury .rolled out of bed at NH (nursing home) .laceration location .behind right ear, 0.5 cm (centimeters) .MD (medical doctor) at bedside .laceration secured with surgiseal . Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed resident returned to facility .from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m . Review of the POS [REDACTED]. Telephone interview with CNA #5 on January 14, 2015, at 11:06 a.m., revealed the CNA was providing incontinence care to the resident in the resident's room, rolled the resident on the resident's … | 2018-05-01 |
| 6646 | 6646 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2015-01-14 | 323 | G | 0 | 1 | WY5111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to prevent an accident during care for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in harm to resident #11. The findings included: Resident #11 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 was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, .Problem .(resident) continues to be at risk for falls d/t (due to) poor safety awareness .Goal .decrease risk for falls related injuries .transfer and mobility with 2 staff . Medical record review of a Status Change dated October 4, 2014, revealed .called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath .head called 911 . Medical record review of a Physician telephone order dated October 4, 2014, revealed .Send to .(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration . Medical record review of a hospital emergency report dated October 4, 2014, revealed, .mechanism of injury .rolled out of bed at NH (nursing home) .laceration location .behind right ear, 0.5 cm (centimeters) .MD (medical doctor) at bedside .laceration secured with surgiseal . Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed resident returned to facility .from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m . Review of the facility policy Fall Prevention Program, revised July 2014, revealed .The Fall Prevention Program is designed to ensure a safe environment for all Residents .Anticipate needs by assess… | 2018-05-01 |
| 6647 | 6647 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2015-01-14 | 490 | G | 0 | 1 | WY5111 | Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to provide effective adminstration to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed .Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement) .When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person (the resident) was afraid of. The CNA on the hall was informed of (resident #87) need .When informed (CNA #1) stated 'It shouldn't have to be this way.' (CNA #1) entered the room. I waited outside the door. The CNA was short with the resident .asked (resident) why .was playing 'in it'. I was unable to hear (resident #87) reply .(CNA #1) made other statem… | 2018-05-01 |
| 8771 | 8771 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2013-12-04 | 323 | D | 0 | 1 | IL8E11 | Based on medical record review, observation, and interview, the facility failed to ensure one resident (#8) of four residents reviewed received adequate supervision and assistive devices to prevent accidents. The findings included: Medical record review of a Care Plan dated November 11, 2013, revealed . (Resident #8) is at risk for injuries/falls .Interventions .Status: Active .Bed Alarm . Medical record review of the Medication Record for December 1, 2013 through December 31, 2013, revealed Bed Alarm when in Bed. Observation of resident #8 with Licensed Practical Nurse (LPN) #1 on December 4, 2013, at 9:10 a.m., revealed the resident lying in bed, eating breakfast. Observation revealed the bed alarm control box secured behind the head board at the head of the bed without the lead wire connected to the box. Continued observation revealed the lead wire connection was laying between the mattress and the side rail and not connected to the alarm. Further observation revealed LPN #1 connected the lead wire to the control box. Observation revealed LPN #1 was not able to test the alarm due to the alarm being turned off. Interview with LPN #1 and the Director of Nursing in the Activity Room on December 4, 2013, at 9:20 a.m., confirmed the bed alarm was turned off with the lead wire disconnected from the control box. Continued interview confirmed the facility had failed to ensure the alarm was working appropriately to alert staff to unassisted tranfers. C/O # | 2017-04-01 |
| 8772 | 8772 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2013-12-04 | 371 | F | 0 | 1 | IL8E11 | Based on observation, facility policy review, and interview, the facility failed to maintain a clean and sanitary kitchen. The findings included: Observation on December 2, 2013, at 7:35 p.m., during the initial tour of the kitchen revealed: 1. Three of three muffin pans with black crusty debris on the inside and outside and one of three muffin pans had rust colored debris on the inside. 2. Five of six size 400 pans with black crusty debris on the inside and outside and three of the five pans had water droplets on the inside and outside. 3. Twenty of twenty-two size 200 pans were dirty with brown and black debris on the inside. 4. Two of two large deep pans (used to cook meat) with crusty brown and white debris on the inside. 5. Two of two shallow pans (used to cook meat) with crusty brown and white debris on the inside. 6. One of one large dessert pan with black and white debris on the inside. 7. Twenty of twenty-one sheet pans with white crusty debris on the inside. Continued observation in the kitchen at the food preparation area revealed: 1. Two of two stack convection ovens with black crusty debris and food particles on the inside at the bottom. 2. Five of six wells on the steam table had food debris and white particles floating in the water. One of the five wells also had hair floating in the water. 3. One of one free standing deep fryer containing black oil with food particles floating in the oil. Unable to visualize the bottom of the deep fryer due to the blackness of the oil. Also food debris on the outside of the fryer. Observation of the front serving area on December 3, 2013, at 7:15 a.m., revealed: 1. The ice tea maker had dark brown sticky areas in numerous areas on the outside of the dispenser. The dispenser was empty. 2. The Juice machine had orange dried sticky substance in numerous areas on the outside of the machine. Review of facility policies for cleaning and sanitizing revealed: 1. .Beverage Fountain .Properly Clean and Sanitize Post-Mix Beverage Machines Procedure Frequency: daily . 2. .Dee… | 2017-04-01 |
| 8773 | 8773 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2013-12-04 | 431 | D | 0 | 1 | IL8E11 | Based on observation, review of facility policy, and interview, the facility failed to ensure all medications were in date for one of three medication carts and in one of two medication rooms. The findings revealed: Observation with Licensed Practical Nurse (LPN) #1 on December 3, 2013, at 7:51 a.m., revealed the 100 hall medication cart contained an open bottle of Aspirin 325 mg (milligram) with an expiration date of December 2012. Observation with the Director of Nursing (DON) on December 3, 2013, at 8:35 a.m., in the 200 hall medication room revealed twelve Ondanestron (antiemetic medication) 4 mg tablets with an expiration date of November 30, 2013, and three Warfarin (blood thinner) 6 mg tablets with an expiration date of August 30, 2012. Review of facility policy, Medication Storage In The Facility, revealed .13. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication destruction . Interview with the DON on December 3, 2013, at 3:40 p.m., confirmed the facility had failed to dispose of all outdated medications. | 2017-04-01 |
| 8774 | 8774 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2013-12-04 | 441 | D | 0 | 1 | IL8E11 | Based on observation and interview, the facility failed to ensure infection control was maintained for one (#43) of six indwelling catheter drainage bags. The findings included: Observation on December 3, 2013, at 8:00 a.m., in the main dining room revealed resident #43 sitting in a geri chair with a covered indwelling catheter drainage bag lying on the floor underneath the seat. Interview with Registered Nurse (RN) #1 at the time of the observation confirmed the indwelling catheter drainage bag was on the floor and should not be there. Interview with the Director of Nursing (DON) on December 4, 2013, at 10:35 a.m., in the DON's office confirmed the facility had failed to maintain infection control by placing the indwelling catheter drainage bag on the floor. | 2017-04-01 |
| 10530 | 10530 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2013-06-04 | 282 | D | 1 | 0 | WDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, review of personnel files and interview, the facility failed to provide incontinence care for one (#8) of nine residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored 5/15 on the Brief Interview for Mental Status (BIMS) with severe cognitive impairment; required extensive assistance of two for bed mobility and transfers; required extensive assistance with dressing; was totally dependent on staff for hygiene and bathing; required assistance with moving from a seated to a standing position, moving on and off the toilet and surface-to-surface transfers; and was incontinent of bowel and bladder. Medical record review of the care plan updated August 15, 2012 revealed the resident was at risk for impaired skin integrity related to decreased mobility and bowel incontinence. Continued review revealed Provide incontinence care following incontinent episodes .[MEDICATION NAME] (multipurpose moisture barrier) PRN (as needed) to buttocks . Review of the personnel file (investigation for allegation of abuse) for Certified Nursing Assistant (CNA) #1 (terminated from the facility on November 6, 2012) revealed Licensed Practical Nurse (LPN) #1 documented a written warning dated August 31, 2012 at 9:30 p.m. for CNA #1. Continued review of the disciplinary action revealed (Resident #8) .so wet (with bowel movement (BM)) brief fell apart-skin gualded (red skin caused by wetness) .Full bed (symbol for change) .BM all over scrotum gualded (gaulded) . Continued review of the personnel file for CNA #1 revealed a second written warning was issued by LPN #2 on November 5, 2012 and noted .(Resident #8) was wet. Resident was not changed or position changed in 5 hrs. (hours) . Telephone interview on May 29, 2013 at 5:50 p.m. with LPN #1 confirmed CNA … | 2016-06-01 |
| 11267 | 11267 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 157 | G | 0 | 1 | CWKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interview, the facility failed to notify the physician of a pressure ulcer for one (#27) of forty residents reviewed. The facility's failure resulted in a delay of physician treatment and harm to resident #27. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident was at risk for developing pressure ulcers, had a stage 3 pressure ulcer (right heel), had a pressure reducing device for the bed, and required extensive assistance with bed mobility. Medical record review of the Wound/Skin Healing Record dated March 7, 2012, revealed, .pre-admit .stage III .Right heel .0.5 x 0.9 x (less than) 0.2 (centimeters) .wound bed brown (eschar) . Medical record review of the Wound/Skin Healing Record dated April 3, 2012, revealed, .(right heel) 0.4 x 0.7 x (less than) 0.2 (centimeters) .granulation tissue .slough .brown eschar . Review of the next Weekly Wound Report dated April 17, 2012, revealed .(right) lateral heel stage 3 0.4 x 0.7 (less than) 0.2 (centimeters) .loose eschar . Medical record review of a skin assessment dated [DATE], revealed, .small area of eschar to (right) heel .0.5 cm x 1 cm .no other skin breakdown noted . Medical record review of a skin assessment dated [DATE], revealed, .healing stage (2) Rt (right) heel Stage (2) coccyx-noted 7/4/12 Reddened area around coccyx .Pressure sores are to be measured weekly by skin assessment nurse . Medical record review revealed the next wound assessment dated [DATE], revealed, . eschar on (right heel) (1cm x 0.5 cm) 2 stage (2) wounds on coccyx ( .3 cm x 1.5 cm) ( .1.5 cm x 1 cm) Excoriated around wound bilat (bilateral) buttocks .Pressure sores are to be measured weekly by the skin assessment nurse . Medical record review of the care plan dated March 15, 2012, revealed .Pe… | 2016-02-01 |
| 11268 | 11268 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 221 | D | 0 | 1 | CWKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, observation, and interview, the facility failed to assess for the use of a restraint for two (#106, #27) residents of forty residents reviewed. The findings included: Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with one person physical assist for bed mobility and transfers. Review of the facility policy, Restraints-Physical, revealed .A physical restraint is defined as any article, device, or garment that is used primarily to modify resident behavior by interfering with free movement .a physician's order is necessary for the use of a physical restraint .The need for restraints will be reevaluated at least quarterly to determine if continued restraint use is necessary to treat the resident's medical symptoms . Observation on July 12, 2012, at 7:40 a.m., with Licensed Practical Nurse (LPN) #2, revealed the resident lying in a low bed with 1/4 siderails up located in the center of the bed to keep the resident from exiting the bed. Observation on July 16, 2012, at 1:30 p.m., with the Director of Nursing (DON) revealed the resident lying in a low bed with 1/4 siderails in the mid bed position. Medical record review revealed no restraint assessment for the use of the siderails. Interview on July 16, 2012, at 12:55 p.m. with the DON, in the conference room, confirmed no assessment had been completed for the use of the siderails as a restraint. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with two person physical assist for bed mobility and total dependence with two person physical assist for transfers, Observation on July 11, 2012, at 7:45 a.m. revealed the resident lying… | 2016-02-01 |
| 11269 | 11269 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 280 | D | 0 | 1 | CWKE12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the care plan for three residents (#2, #9, and #14) of eighteen residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].may replace foley catheter if does not void before 7pm tonight . Medical record review of the current Interdisciplinary Care Plan last reviewed August 10, 2012, revealed no updates to reflect the indwelling catheter was discontinued on July 17, 2012. Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been revised to reflect the resident no longer had an indwelling uninary catheter. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August 2012, revealed .change 20 Fr (French) Foley cath (catheter) prn (as needed) . Medical record review of the current Interdisciplinary Care Plan last reviewed August 14, 2012, revealed .foley cath change Q (every) month and PRN . Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been updated to reflect the resident's indwelling urinary catheter was to be changed as needed not every month. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August 2012, revealed .change foley cath prn . Medical record review of the current Interdisciplinary Care Plan last reviewed August 14, 2012, revealed .change foley cath 1 time monthly . Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been updated to reflect the resident's indwelling urinary catheter was to be changed as needed not every month. | 2016-02-01 |
| 11270 | 11270 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 281 | D | 0 | 1 | CWKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medication record review, and interview, the facility failed to follow physician's orders for medication administration for one (#39) of forty sampled residents. The findings included: Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed an initial psychiatric consult was obtained on May 11, 2012, for depression and medication management. Further review revealed the resident had been having increasingly paranoid thoughts. Further review revealed the resident was accusing staff of morbid acts such as killing the resident and taking out the resident's arteries. Medical record review revealed the resident was admitted to the hospital on May 18, 2012, and returned to the facility on [DATE]. Medical record review revealed a physician's order dated May 31, 2012, for [MEDICATION NAME] (antipsychotic medication) 20 mg.(milligrams) to be given daily at 5:00 p.m. Medical record review of the physician's signed recapituation (recap) orders for June 2012, revealed order for [MEDICATION NAME] 20 mg. to be given at 5:00 p.m., prn (as necessary). Review of the Medication Administration Record [REDACTED] Review of the Psychiatric Consultation Follow Up dated June 25, 2012, revealed the resident continued to have delusions and paranoia and the recommendation was to continue [MEDICATION NAME] 20 mg. daily at 5:00 p.m. Medical record review of the MAR for July 2012, revealed no documentation [MEDICATION NAME] 20 mg. was given on July 3 or 4, 2012. Interview with the Director of Nursing (DON) in the DON's office on July 11, 2012, at 2:45 p.m., confirmed the physician order sheet for June 2012, had been incorrectly transcribed and the resident was to have received [MEDICATION NAME] 20 mg. daily (not prn). Further interview confirmed the resident had not received [MEDICATION NAME] 20 mg. as ordered by the physician in June or July 2012. | 2016-02-01 |
| 11271 | 11271 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 282 | D | 0 | 1 | CWKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow a care plan for indwelling catheter changes for one (#39) of forty residents reviewed. The findings included: Resident #39 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated May 24, 2012, revealed intervention of change .catheter and drainage bag every thirty days and prn (as necessary). Medical record review of hospital documentation revealed the resident's catheter was changed while in the hospital on May 21, 2012, with orders to change monthly. Medical record review revealed no documentation of a catheter change since readmission (fifty-one days). Interview with the Director of Nursing (DON) in the DON's office on July 11, 2012, at 2:45 p.m., confirmed the resident's urinary catheter had not been changed since readmission on May 21, 2012. | 2016-02-01 |
| 11272 | 11272 | AGAPE NURSING AND REHABILIATION CENTER, LLC | 445162 | 505 N ROAN STREET | JOHNSON CITY | TN | 37604 | 2012-07-16 | 309 | D | 0 | 1 | CWKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for antipsychotic medication for one (#17) of forty residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severe cognitive impairment and required assistance with all activities of daily living. Medical record review revealed the resident was placed on [MEDICATION NAME] (antipsychotic) 0.5 mg. (milligrams) twice daily on July 13, 2011. Medical record review revealed a physician's order dated June 26, 2012, to decrease [MEDICATION NAME] to 0.25 mg. every morning and 0.25 mg. at bedtime. Review of the Medication Administration Record [REDACTED]. Review of the physician's recapituation orders for July 2012, revealed an order for [REDACTED]. Interview with the Director of Nursing (DON) in the hallway on July 12, 2012, at 9:45 a.m., confirmed the medication order had been transcribed incorrectly on the physician's recap orders and the resident was to receive [MEDICATION NAME] 0.25 mg. at bedtime. Medical record review of the MAR for July, 2012, revealed no documentation [MEDICATION NAME] 0.25 mg. was given at bedtime on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11, 2012 (11 days). Observation on July 12, 2012, at 9:45 a.m., revealed the resident lying in bed with eyes closed. Interview with the DON in the hallway on July 12, 2012, at 9:45 a.m., confirmed the resident did not receive the bedtime dosage of [MEDICATION NAME] from June 26, through July 11, 2012, and no [MEDICATION NAME] 0.25 mg. morning dose was administered on June 27 - 30, 2012. | 2016-02-01 |
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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 );