cms_TN
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14,361 rows sorted by scope_severity
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 329 | 329 | ALEXIAN VILLAGE OF TENNESSEE | 445123 | 671 ALEXIAN WAY | SIGNAL MOUNTAIN | TN | 37377 | 2017-10-25 | 253 | B | 0 | 1 | QBNE11 | Based on observation and interview, the facility failed to maintain the walls in good repair in 4 of 19 rooms on 1 of 4 floors. The findings included: Observation of room 505 on 10/23/17 at 2:15 PM revealed there were several areas with white mudding (compound to smooth drywall) on the painted green wall at the head of the bed. Observation and interview with the Maintenance Director on 10/24/17 at 3:50 PM of the wall in room 505 revealed there were 9 areas of mudding on the wall, with the largest area measuring approximately 36 inches in length. Continued interview confirmed the wall was in need of repair/painting. Interview with the facility's painter with the Maintenance Director present on 10/24/17 at 4:00 PM, in the hallway revealed the wall had been mudded 6 months ago and confirmed the green wall had not been repainted after the mudding. Observation and interview with the Maintenance Director on 10/25/17 at 9:30 AM of the walls in rooms 503, 513, and 519, confirmed the walls had areas of sheetrock showing and were in need of repair. | 2020-09-01 |
| 352 | 352 | NHC HEALTHCARE, OAK RIDGE | 445128 | 300 LABORATORY RD | OAK RIDGE | TN | 37831 | 2017-02-01 | 161 | B | 0 | 1 | CP8M11 | Based on facility records review and interview, the facility failed to provide a Surety Bond to cover the residents' personal funds account. The findings included: Review of the daily ledger balance summary for the residents' personal funds dated 12/1/16 through 12/31/16 revealed the following balances: 1) 12/2/16 with a balance of $42,126.24 2) 12/5/16 with a balance of $41,265.53 3) 12/6/16 with a balance of $41,665.53 4) 12/7/16 with a balance of $19,884.93 5) 12/8/16 with a balance of $19,849.93 Review of a facility letter from the insurance company dated 12/5/16 revealed a bond amount of $18,000.00. Interview with the Administrator on 2/1/17 at 7:45 AM in the conference room, confirmed the Surety Bond amount was $18,000.00 and the resident trust balance had been more than $18,000.00 on 5 occasions in (MONTH) (YEAR). | 2020-09-01 |
| 5678 | 5678 | LAURELWOOD HEALTHCARE CENTER | 445413 | 200 BIRCH ST | JACKSON | TN | 38301 | 2015-08-12 | 156 | B | 0 | 1 | Z3X911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #46 and 64) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #46 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 06.08.15 and on 06.09.15 . The form was signed but not dated by the Patient / Representative. Interview with the Social Worker on 3/12/15 at 2:30 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #46 was not dated by the Patient/Representative. 2. Review of the Notice of Medicare Non-Coverage for Resident #64 documented, .The Effective Date Coverage of Your Physical, Speech, and Occupational Therapy Services Will End: 07.7.15 . The Patient/Representative signed and dated the form on 7/14/15. Interview with the Social Worker on 3/12/15 at 2:35 PM, in room [ROOM NUMBER], confirmed that the Notice of Medicare Non-Coverage for Resident #64 was not signed and dated by the Patient / Representative prior to the effective date of non-coverage. | 2019-01-01 |
| 10442 | 10442 | VANCO MANOR NURSING AND REHABILITATION CENTER, INC | 445460 | 813 S DICKERSON RD | GOODLETTSVILLE | TN | 37072 | 2013-04-19 | 425 | B | 0 | 1 | VETJ11 | Based on review of facility documentation, review of facility policy, and interview the facility failed to provide pharmacy services to four residents of thirty-three residents reviewed. The findings included: Review of facility documentation Borrowed Medication Log revealed four narcotics had been borrowed from four residents to administer to other residents April 2-8, 2013. Review of facility policy Borrowing of Meds dated February 2013, revealed .The practice must be limited to the exceptional occasion when a medication is needed and cannot be obtained from the pharmacy or the backup pharmacy . Interview with the Director of Nursing (DON), on April 18, 2013, at 9:13 a.m., in the DON Office, confirmed the backup pharmacy does not provide narcotics to the facility. Continued interview confirmed the facility borrowed four narcotics from residents to administer to other residents. | 2016-07-01 |
| 10587 | 10587 | BETHESDA HEALTH CARE CENTER | 445427 | 444 ONE ELEVEN PLACE | COOKEVILLE | TN | 38501 | 2013-02-12 | 371 | B | 0 | 1 | DN0M11 | Based on observation and interview the facility failed to provide sanitary storage of food in one of two resident nourishment refrigerators. The findings included: Observation of the south hall resident nourishment refrigerator on February 11, 2013, at 2:50 p.m., revealed: 1. a one gallon container of fruit punch one-third full opened and not labeled 2. a half pint container of whole milk, half full, opened and not labeled 3. two one liter containers of bottled water one-third full, opened and not labeled 4. a ten ounce container of orange juice half full, opened and not labeled Interview with the Director of Nursing and the Licensed Dietitian, at that time, confirmed the beverages should be dated when opened and labeled with the resident's name. | 2016-06-01 |
| 13030 | 13030 | NORRIS HEALTH AND REHABILITATION CENTER | 445303 | 3382 ANDERSONVILLE HIGHWAY | ANDERSONVILLE | TN | 37705 | 2011-05-25 | 372 | B | 0 | 1 | V14O11 | Based on observation and interview the facility failed ensure garbage and refuse were properly disposed of. The findings included: Observation of the facility's dumpsters on May 23, 2011, at 12:30 p.m., with the Dietary Manager (DM), revealed the dumpster area with scattered refuse including: three disposable latex gloves, six plastic straws, three plastic cups, two candy wrappers, two used sweetener packets, and plastic utensils (a fork and knife) on the ground surrounding the dumpster. Interview with the DM, at the time of the observation, confirmed the dumpster area was not clean and well maintained. | 2015-05-01 |
| 13159 | 13159 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2015-02-11 | 371 | B | 0 | 1 | PJXT11 | Based on observation and interview, the facility failed to store food in a sanitary manner to prevent cross-contamination between resident food items and non-food items for three of seven refrigerator/freezers designated for resident snacks, on two of four units observed. The findings included: Observation with Licensed Practical Nurse (LPN) #4 on February 10, 2015, at 12:55 p.m., of the station 1 nourishment refrigerator/freezer, revealed individual servings of ice cream for resident use stored in the freezer. Continued observation revealed three ice packs had been stored on the door rack of the freezer (one freezer gel pack and two solid ice packs). Observation with LPN #3 on February 10, 2015, at 1:00 p.m., of the station 4 nourishment refrigerator/freezer located in the Kitchen/Ice Machine room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one solid ice pack had been stored on the door rack of the freezer. Observation with LPN #3 on February 10, 2015, at 1:05 p.m., of the station 4 nourishment refrigerator/freezer located in the Med (medication) Prep (preparation) Room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one gel freezer pack had been stored in the freezer next to the resident's ice cream. Interview with LPN #2 on February 10, 2015, at 2:15 p.m., at nurse's station 4, confirmed the ice packs were not to be stored with the food items. Interview with the Registered Dietician on February 10, 2015, at 4:15 p.m., in the Parkwood Dining Room, confirmed non-food items were not to be stored with the resident's snacks. | 2015-04-01 |
| 9 | 9 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 574 | C | 0 | 1 | UNET11 | Based on facility policy review, admission packet review, interview, and observation, the facility failed to support each resident's rights by ensuring the required State Survey Agency's contact information was made available for 3 of 3 residents (Resident #1, Resident #2, and Resident #16). Interviews obtained during the resident group meeting revealed the residents had not been given information on how to file a complaint with the State Survey Agency. This failure had the potential to affect all 43 residents of the facility who may want to exercise their right to file a complaint directly with the State Survey Agency. Findings include: Review of the facility's policy titled, Patient Rights and Responsibilities-Siskin West Subacute, undated, revealed the residents had the right to .contact the Tennessee Department of Health directly at (telephone number) to lodge any concerns you may have about your care. Review of the facility's policy titled, Resident Rights, undated, located in the facility's admission packet provided during the entrance conference, revealed at the time of admission, and periodically through their stay, the facility would inform each resident, orally and in writing, of their rights. The policy stated the resident had the right to voice grievances to the facility, or other agency or entity that hears grievances, without discrimination or reprisa,l and without fear of discrimination or reprisal. The policy also stated the resident had the right to be afforded the opportunity to contact these agencies. The policy stated the resident had the right to immediate access to any of the following: any representative of the Secretary of the U.S. Department of Health and Human Services, any representative of the State, the resident's individual physician, the State's long-term care ombudsman, and the agency responsible for the protection of, and advocacy system for, mentally or developmentally disabled individuals. Review of an untitled and undated form, located in the Admission Packet provided by the fa… | 2020-09-01 |
| 163 | 163 | CHRISTIAN CARE CENTER OF UNICOI COUNTY | 445077 | 100 GREENWAY CIRCLE | ERWIN | TN | 37650 | 2019-06-05 | 640 | C | 0 | 1 | 2MLG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview the facility failed to submit a discharge Minimum Data Set (MDS) discharge assessment timely for one resident (#2) of 1 resident reviewed for discharge MDS assessments of 21 sampled residents. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be submitted .within 14 days after the MDS completion date . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #2 was discharged home on[DATE]. Medical record review of the MDS assessments revealed a discharge assessment was completed on 1/1/19. Interview with Registered Nurse (RN) Information Nurse Consultant on 06/05/19 at 1:50 PM, in the Executive Director's office revealed .discharge assessment was completed but was never transmitted . Continued interview confirmed the facility failed to submit a discharge assessment for the 1/1/19 discharge for Resident #2. | 2020-09-01 |
| 261 | 261 | HEALTH CENTER AT STANDIFER PLACE, THE | 445111 | 2626 WALKER RD | CHATTANOOGA | TN | 37421 | 2019-07-31 | 569 | C | 0 | 1 | 77NT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, review of the facility's documentation of the Notification Summary Report (resident trust funds/Resident Statement), and interview, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for 2 discharged residents (#402 and #403) of 313 Patient Trust Funds reviewed. The findings include: Review of the facility policy, Patient Trust, Subject: Refunds, revised date ,[DATE], revealed .Timing (Schedule) the funds should be refunded within 30 days of death or discharge . Medical record review revealed Resident #402 was admitted to the facility on [DATE]. Continued review revealed the Resident was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #402 had a balance of $1719.70. Medical record review revealed Resident #403 was admitted to the facility on [DATE]. Continued review revealed Resident #403 was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #403 had a balance of $1686.57. Interview with the Trust Bookkeeper on [DATE] at 8:40 AM, in the business office, confirmed the facility had not refunded the Resident's Trust Fund accounts for Residents #402 and #403. Continued interview confirmed the facility had not refunded the accounts within the required time frame. | 2020-09-01 |
| 301 | 301 | WESTMORELAND HEALTH AND REHABILITATION CENTER | 445114 | 5837 LYONS VIEW PIKE | KNOXVILLE | TN | 37919 | 2018-10-11 | 814 | C | 0 | 1 | SM1F11 | Based on observation and interview, the facility failed to maintain a lid on 1 of 1 dumpster to prevent vermin from entering the dumpster. The findings include: Observation and interview on 10/8/18 at 9:55 AM, with the Dietary Manager outside of the facility at the dumpster site, revealed the garbage dumpster did not have a lid to prevent possible vermin from entering the dumpster. Interview with the Dietary Manager confirmed the dumpster did not have a lid in place. | 2020-09-01 |
| 357 | 357 | NHC HEALTHCARE, OAK RIDGE | 445128 | 300 LABORATORY RD | OAK RIDGE | TN | 37831 | 2018-02-28 | 881 | C | 0 | 1 | 4KZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Center Statement, review of the Antibiotic Stewardship Notebook and Infection Control Records, and interview, the facility failed to implement an Antibiotic Stewardship program for 98 of 98 residents in the facility. The findings included: Review of the facility Center Statement: Antibiotic Stewardship undated revealed .( Name of facility) is committed to establish and implement practices to maximize treatment of [REDACTED]. Review of the Antibiotic Stewardship Notebook and Infection Control Records with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the Assistant Director of Nursing office, revealed no system was in place to monitor antibiotic usage in the facility for residents with infections. Interview with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the ADON's office, confirmed .I don't surveillance antibiotics .There is no written antibiotic protocol .I review labs and cultures at the end of the month .We have no antibiotic policy just a mission statement . Continued interview confirmed she was not aware of the specific infections and the antibiotic medications prescribed in the facility. Further interview confirmed the facility had not developed, promoted or implemented a system to monitor use of antibiotics in the facility. | 2020-09-01 |
| 379 | 379 | SEVIERVILLE HEALTH AND REHABILITATION CENTER | 445132 | 415 CATLETT RD | SEVIERVILLE | TN | 37862 | 2020-01-16 | 582 | C | 0 | 1 | 8CXC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 2 of 3 residents (Resident #20 and Resident #33) with the Advanced Beneficiary Notice, Center for Medicare and Medicaid Services (CMS)- when they ended therapy services and remained in the facility for long-term care services. This failure left residents without information related to the cost of therapy services if they desired to continue them in the facility and did not allow for them to have informed choice. Findings include: Resident #20 was admitted on [DATE] for a Medicare A stay. He had [DIAGNOSES REDACTED]. He received physical therapy, occupational therapy, and speech language therapy. The Social Service Director (SSD) issued the Notice of Medicare Non-Coverage (CMS- ) on 10/2/2019 informing him therapy services would end on 10/7/2019. The SSD did not issue the CMS- Advance Beneficiary Notice to the resident. The resident remained in the facility for long-term care and had Medicare benefit days remaining. Resident #33 was re-admitted on [DATE] after a hospital stay. His admitting [DIAGNOSES REDACTED].#33 received speech language therapy upon returning to the facility. The SSD issued the CMS- informing him that therapy would be ending on 12/20/2019. The CMS- was not issued to the resident or Family Member #33 indicating why the Medicare therapy services would no longer be covered and the cost of the therapy services, and the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Interview with the SSD on 1/14/2020 at 12:01 PM revealed she was responsible for issuing all beneficiary notices. She stated she did not issue the CMS- to any residents remaining in the facility that had Medicare days remaining. She further stated the interdisciplinary team reviewed all Medicare residents and determined as a team that the individual no longer met Medicare requirements. She state… | 2020-09-01 |
| 556 | 556 | QUALITY CENTER FOR REHABILITATION AND HEALING LLC | 445154 | 932 BADDOUR PARKWAY | LEBANON | TN | 37087 | 2018-05-03 | 803 | C | 0 | 1 | X9ZT11 | Based on review of nutritional guidelines, menu review, and interview, the facility menu failed to meet nutritionally adequate standards for 3 of 4 weeks in the menu cycle. Findings include: Review of the Nutritional Guidelines and Menu Checklist for Residential and Nursing Home, 2014, revealed 5 or more servings of fruit and vegetables should be served daily. Further review revealed food high in fat should be used sparingly. Review of the 4 week cycle menu revealed the following: Week 1 Sunday Supper was Hamburger on Bun, French Fries, Fudge Round, and Lettuce/[NAME]to/Onion. Week 1 Monday Lunch was Tuna Salad on Bun, Tator Tots, Soup, Donuts. Week 1 Tuesday Lunch was Corn Dog Nuggets, French Fries, Cookie. Week 1 Friday Lunch was Grilled Chicken Breast, Macaroni Salad, Waffle Fries. Supper was Pizza, Tossed Salad (no tomato), Fruit. Week 1 Saturday Lunch was Hot Dog on Bun, Chili, Saltine Crackers, Tator Tots, Donut. Week 3 Sunday Lunch was Fish Sandwich, French Fries, Macaroni Salad, Cookie. Week 3 Wednesday Lunch Corn Dog, Tator Tots, Baked Beans, Cookie. Supper was Chicken Nuggets, French Fries, Mixed Vegetables, Honey Bun. Week 3 Thursday Lunch was[NAME]Wagon Burger, French Fries, Lettuce/[NAME]to/Onion, Fig Newton. Week 4 Sunday Lunch was Fish Sandwich, French Fries, Fruit Cup, Fig Newton. Week 4 Tuesday Lunch was Cheese Pizza, Tossed Salad, (no tomato) Cookie. Supper was Corn Dog Nuggets, French Fries, Baked Beans, Fruit Parfait. Week 4 Thursday Supper was Hamburger on Bun, Fries, Lettuce/[NAME]to/Onion, Donuts. Week 4 Saturday Supper was Corn Dog, Tator Tots, Fruit Salad, Italian Ice. Review of the menu cycle revealed the menu failed to have 5 or more servings of fruit and vegetables daily. Interview with 13 Resident Council members on 4/30/18 at 2:00 PM in the Dining Room revealed the residents complained of meals being served cold on a daily basis. Further interview revealed the residents also complained of fried foods and sandwiches frequently served. Interview with the Dietary Manager (DM) on 5/1/18 … | 2020-09-01 |
| 582 | 582 | DIVERSICARE OF CLAIBORNE | 445156 | 902 BUCHANAN RD | NEW TAZEWELL | TN | 37825 | 2019-06-25 | 661 | C | 0 | 1 | D0TQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge for 3 residents (#92, #94, #248) of 6 residents reviewed for transfer/discharge requirements. The findings include: Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the facility' discharge transfer/discharge documentation dated 5/10/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 4/19/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #248 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 1/24/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Interview with the Minimum Data Set Coordinator on 6/25/19 at 12:20 PM, in the conference room, confirmed the transfer/discharge form was the only documentation the facility completed with the Physician's signature. | 2020-09-01 |
| 611 | 611 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2017-05-10 | 356 | C | 1 | 0 | DC3711 | > Based on observation and interview, the facility failed to post the nurse staffing information for 3 of 6 days. The findings included: Observation on 5/8/17 at 8:25 AM revealed the nurse staffing information form posted by the main entrance lobby area was dated 5/4/17, Thursday. Interview with the Main Entrance Receptionist on 5/8/17 at 8:45 AM by the posted nurse staffing information form in the main entrance lobby area confirmed the form was dated 5/4/17. Further interview revealed the Receptionist posted the nursing staff information form Monday through Friday. Further interview revealed the Receptionist did not receive the nurse staffing information forms in order to post them on Friday. Interview with the Staff Development Director (SDD) on 5/9/17 at 10:45 AM by the posted nurse staffing information in the main entrance area confirmed the SDD was responsible to fill out the nurse staffing information forms. Further interview revealed the SDD was to give the nurse staffing information forms to the receptionist on Thursday to post for Friday, Saturday and Sunday. Further interview confirmed the SDD failed to provide the staffing information forms to the receptionist for 5/5/17, 5/6/17, and 5/7/17 and the information was not posted. | 2020-09-01 |
| 702 | 702 | THE HEALTH CENTER AT RICHLAND PLACE | 445166 | 504 ELMINGTON AVENUE | NASHVILLE | TN | 37205 | 2019-06-13 | 732 | C | 0 | 1 | TUZL11 | Based on observation and interview, the facility failed to update the daily posted staffing and census on 6/8/19 and 6/9/19. The findings include: Observation on 6/10/19 at 8:39 AM on the main hallway wall revealed the posted staffing and census was dated 6/7/19. Interview with the Director Of Nursing on 6/13/19 at 5:29 PM in the conference room confirmed .we usually have the weekend Admission Nurse to post the daily staffing and census. She took the weekend off and we got somebody to cover the admission part but forgot to update them on that part (posting the daily staffing and census sheet daily) . | 2020-09-01 |
| 706 | 706 | THE HEALTH CENTER AT RICHLAND PLACE | 445166 | 504 ELMINGTON AVENUE | NASHVILLE | TN | 37205 | 2018-06-27 | 732 | C | 0 | 1 | ITMM11 | Based on observation and interview, the facility failed to update the posted staffing and census on 6/23/18 and 6/24/18. Findings included: Observation on 6/25/18 at 8:08 AM on the main hallway wall revealed the posted staffing and census was dated 6/22/18. Interview with the Administrator on 6/25/18 at 1:30 PM in the private dining room confirmed the facility failed to update the posted staffing and census for 6/23/18 and 6/24/18. | 2020-09-01 |
| 853 | 853 | GALLATIN HEALTH CARE CENTER, LLC | 445183 | 438 NORTH WATER AVE | GALLATIN | TN | 37066 | 2017-12-19 | 732 | C | 1 | 0 | RPNN11 | > Based on observation and interview, the facility failed to post the current daily staffing for 1 of 5 days of the survey. The findings included: Observation on 12/12/17 at 7:15 AM in the main lobby and hall area, with various informational postings for families and residents, revealed the posted staffing and census form was dated 11/20/17. Interview with Licensed Practical Nurse #11 on 12/12/17 at 7:30 AM in the conference room, after reviewing the posted staffing form, confirmed the posted staffing and census was dated 11/20/17. Interview with the Director of Nursing at 8:35 AM in the conference room confirmed the posted staffing form dated 11/20/17 was not current. | 2020-09-01 |
| 965 | 965 | WOODLAND TERRACE CARE AND REHAB | 445205 | 8249 STANDIFER GAP ROAD | CHATTANOOGA | TN | 37421 | 2019-01-16 | 577 | C | 0 | 1 | HIXZ11 | Based on observation and interview, the facility failed to provide the most recent survey results for resident and public review in the facility's survey notebook. The findings include: Observation on 1/14/19 at 11:45 AM, at the facility entrance, revealed a survey notebook on a table. Continued obsevation revealed the contents of the notebook did not contain the survey results from the last recertification survey from 2/6/18. Interview with the Administrator on 1/14/19 at 2:30 PM, in the Administrator's office confirmed the survey results from 2/6/18 had not been placed in the notebook. | 2020-09-01 |
| 1235 | 1235 | LIFE CARE CENTER OF RED BANK | 445240 | 1020 RUNYAN DR | CHATTANOOGA | TN | 37405 | 2017-05-17 | 356 | C | 0 | 1 | VSOY11 | Based on facility documentation review and interview the facility failed to retain accurately posted staffing data. The findings included: Review of the Staffing Posted Data from 11/17/16-5/17/17 revealed the following: A) The Facility's name was not documented on the staffing posted data forms from 6/2016-5/16/17. B) Incomplete documentation on staffing data posted forms including the date, the total and actual hours worked by Registered Nurses, License Practical Nurses, Certified Nursing Assistants and the resident census on multiple forms. C) Missing staffing posted data forms for multiple dates. Interview with the Administrator on 5/17/17 at 5:43 PM, in the Administrator's Office confirmed the facility failed to document the facility's name on all staffing posted data forms from 6/2016 to 5/17/17. Continued interview confirmed the facility failed to complete documentation on forms including the date, total and actual hours worked by Registered Nurses, Licensed Nursing Staff, Certified Nursing Assistants, and the resident census for multiple dates. Further interview confirmed the facility failed to retain staffing data forms for multiple dates. | 2020-09-01 |
| 1372 | 1372 | HARTSVILLE CONVALESCENT CENTER | 445256 | 649 MCMURRY BLVD | HARTSVILLE | TN | 37074 | 2018-12-12 | 732 | C | 0 | 1 | IZRR11 | Based on policy review, observation and interview, the facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care each shift for 3 of 3 days during the survey. The findings include: Review of an undated facility policy, Posting Daily Nurse Staffing, revealed .This center will post daily nurse staffing per CMS (Centers for Medicare and Medicaid Services) and the State of Tennessee requirements . Observation on 12/10/18, 12/11/18 and 12/12/18 of the posted daily staffing sheets posted in front of the Director of Nurse's (DON) office revealed no posting of the total number of staff responsible for resident care. Interview with the DON on 12/12/18 at 7:33 AM in her office confirmed she did not post the number of staff on the daily posting sheet. She stated I don't post the numbers, just the staff. | 2020-09-01 |
| 1381 | 1381 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2017-03-08 | 356 | C | 0 | 1 | FXLB11 | Based on observation and interview, the facility failed to post the nurse staffing correctly for one of three days observed. The findings included: Observation and interview with the Director of Nursing on 3/6/17 at 8:50 AM, in the hall, confirmed the Posted Nurse staffing did not include the number of staff working and the census for 3/6/17. | 2020-09-01 |
| 1384 | 1384 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2018-05-03 | 577 | C | 0 | 1 | 2DL711 | Based on observation and interview, the facility failed to ensure the most recent survey results were readily accessible for all 92 residents residing in the facility. The findings included: Observation in the facility lobby on 5/1/18 revealed a white binder with survey results from the facility's last annual survey on 3/8/17. Continued observation revealed no documentation of the facility's most recent survey results from a complaint investigation conducted on 9/5/17. Interview with the Administrator on 5/3/18 at 7:58 PM, in the Administrator's office, confirmed the facility had not included the most recent survey results in their annual survey binder located in the facility's lobby, .it was an oversight . | 2020-09-01 |
| 1436 | 1436 | BRIARCLIFF HEALTH CARE CENTER | 445260 | 100 ELMHURST DR | OAK RIDGE | TN | 37830 | 2017-01-11 | 356 | C | 0 | 1 | TU9H11 | Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 1/9/17 at 8:35 AM, in the facility main hallway, revealed the nurse staffing sheet posted was dated 1/7/17 and 01/8/17. Interview with Registered Nurse #1 on 1/9/17 at 8:50 AM, in the facility main hallway, confirmed the nurse staffing sheet posted was not for the current date. | 2020-09-01 |
| 1490 | 1490 | LAUGHLIN HEALTH CARE CENTER | 445264 | 801 E MCKEE ST | GREENEVILLE | TN | 37743 | 2018-01-10 | 838 | C | 0 | 1 | Y2ZQ11 | Based on review of the Facility Assessment Tool and interview the facility failed to conduct a facility-wide assessment. The findings included: Review of the Facility Assessment Tool, dated 8/18/17 revealed no documentation a facility assessment had been conducted. Interview with the facility Administrator on 1/10/18 at 1:29 PM in the conference room confirmed the facility had failed to conduct a facility assessment. | 2020-09-01 |
| 1492 | 1492 | LAUGHLIN HEALTH CARE CENTER | 445264 | 801 E MCKEE ST | GREENEVILLE | TN | 37743 | 2018-01-10 | 881 | C | 0 | 1 | Y2ZQ11 | Based on facility policy review and interview the facility failed to implement an Antibiotic Stewardship Program. The findings included: Review of the facility policy, Antibiotic Stewardship Program undated revealed .It is the policy .to implement and maintain an Antibiotic Stewardship Program . Interview with the Director of Nursing (DON) on 1/9/18 at 2:40 PM, in the DON's office confirmed the facility had failed to implement an Antibiotic Stewardship Program. | 2020-09-01 |
| 1568 | 1568 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2017-02-01 | 159 | C | 0 | 1 | OV2211 | Based on review of Resident trust fund (personal fund) account records and interview, the facility failed to provide quarterly Resident personal fund statements for 52 residents of 52 residents or their legal representative with personal funds accounts for the 10/2016 through 12/2016 quarter. The findings included: Review of the quarterly Personal Funds accounts statements dated 10/2016-12/2016 revealed 52 residents had a Personal Funds account with the facility. Continued review revealed the quarterly statements accounted for the residents' Personal Funds account money. Further review revealed Resident #13 was one of the 52 residents who had a Personal Funds account with the facility. Telephone interview with Resident #13's legal representative on 1/30/17 at 3:48 PM revealed he had never received a quarterly statement for the Resident's Personal Funds account. Interview with the Director of Human Resources (DHR) on 2/1/17 at 9:05 AM in the front office revealed the facility had only supplied personal funds statements upon request. Further interview with the DHR confirmed the facility failed to provide residents or their legal representative with quarterly Personal Funds account statements. | 2020-09-01 |
| 1570 | 1570 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2017-02-01 | 254 | C | 0 | 1 | OV2211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain bed and bath linens in good condition for resident use. The findings included: Observation on 1/30/17 at 11:07 AM on the B Hall, room [ROOM NUMBER], restroom revealed a frayed washcloth with holes hanging on the towel bar. Observation on 1/30/17 at 11:53 AM on the C Hall, room [ROOM NUMBER], revealed a blanket on the bed in use by the resident with torn, frayed edges along two sides. Observation on 1/30/17 at 3:38 PM on the D Hall, room [ROOM NUMBER]B, revealed a blanket on the bed in use by the resident with frayed edges on the hem of the blanket. Observation on 1/30/17 at 4:12 PM on the B Hall, room [ROOM NUMBER] restroom revealed a towel with holes hanging on the towel bar. Observations on 1/31/17 beginning at 8:53 AM revealed the D Hall linen cart contained frayed, torn towels. A second linen cart on D hall located by the shower room contained 1 blanket with frayed, torn edges and towels with frayed edges. The B Hall linen cart contained thin wash cloths and thin towels. Observations on 2/1/17 beginning at 10:45 AM while conducting a walk through tour of the facility with the Housekeeping Supervisor and the Maintenance Supervisor to observe surveyor team concerns revealed: 1.Hall B, room [ROOM NUMBER], towel hanging on towel rack that was worn thin with frayed edges and holes; 2.Linen Cart on B hall with washcloths, towels, and blankets that were worn thin and frayed; 3.Linen Cart on D hall with washcloths and towels that were worn thin and frayed. Interview with the Housekeeping Supervisor on 2/1/17 at 11:30 AM near the A/B nurses station confirmed the facility had failed to maintain bed and bath linens in good condition and available for resident use. | 2020-09-01 |
| 1770 | 1770 | HOLSTON MANOR | 445295 | 3641 MEMORIAL BLVD | KINGSPORT | TN | 37664 | 2018-11-28 | 620 | C | 0 | 1 | S68D11 | Based on review of a facility admission agreement, facility policy review, and interview, the facility failed to establish an admission policy which did not request or require residents or potential residents to waive potential facility liability for losses of personal property for all 126 residents currently residing in the facility. The findings include: Review of the facility's Admission Agreement, undated, revealed .Personal Property and Valuables .Resident or Resident Representative agrees to be responsible for all valuables .personal property in his or her possession while the Resident is at the Facility. The facility shall not be responsible for lost, damaged or stolen items . Review of a facility policy, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised (MONTH) (YEAR), revealed .Residents are not required or requested to waive facility liability for loss or misappropriation of personal property . Interview with the Administrator on 11/28/18 at 10:23 AM, in the Administrator's Office, confirmed the facility does not have to reimburse for missing/lost items. Further interview revealed the admission agreement signed by the resident or the resident's Power of Attorney (POA) upon admission stated the facility is not responsible for lost or missing personal property. Continued interview confirmed all residents or POAs are required to sign the admission agreement upon admission. | 2020-09-01 |
| 1835 | 1835 | SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT | 445306 | 215 HIGHLAND CIRCLE DRIVE | PORTLAND | TN | 37148 | 2019-02-07 | 732 | C | 0 | 1 | OXBH11 | Based on facility policy review, observation and interview, the facility failed to update the daily posted staffing from 1/29/19 though 2/4/19 (6 days). The findings include: Review of the facility policy, Posting of Nurse Staffing, dated 6/28/18 revealed .On a daily basis, at the beginning of the shift, the facility must have posted or available for review the following data .Facility name .Current date .Resident Census .The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered Nurses, Licensed Practical Nurses or licensed vocational nurses .Certified nurse aide . Observation on 2/4/19 at 9:01 AM revealed .Daily Staffing Form . was dated 1/29/19 (6 days). Interview with Certified Nursing Assistant (CNA) #1 who also works in central supply on 2/6/19 at 2:21 PM in the conference room revealed (CNA #1) was responsible for updating and posting the staffing form Monday through Friday. Further interview revealed .the MOD (Manager on Duty) was supposed to post the daily staffing form on the weekends and when (CNA #1) went on leave . Further interview revealed when asked if (CNA #1) updated the daily staffing form for 2/4/19 she stated .I did not do it that day, I teched (worked on the floor) on that day and (MONTH) 1st I stocked supplies . Interview with the Interim Director of Nursing on 2/6/19 at 5:52 PM in her office confirmed .I expect the daily staffing post to be posted no later than 9 AM . Continued interview confirmed the Daily Staffing form was not posted from 1/29/19 through 2/4/19 (6 days). | 2020-09-01 |
| 2068 | 2068 | WESTMORELAND CARE & REHAB CTR | 445342 | 1559 NEW HIGHWAY 52 | WESTMORELAND | TN | 37186 | 2017-04-20 | 356 | C | 0 | 1 | 1EAK11 | Based on observation and interview, the facility failed to post staffing requirements for 79 of 79 days reviewed. The findings included: Observations on 4/17/17 to 4/20/17 revealed the Daily Staffing Form posted on the large bulletin board in the hallway near the commons area. Continued observation revealed the actual hours worked were not documented on any of the forms for these dates. Further review of the Daily Staffing Forms for February, March, and (MONTH) (YEAR) revealed the actual hours worked were not documented on any of the forms. Interview with the Administrator and the Director of Nursing on 4/20/17 at 8:34 AM, in the Administrator's office, when shown the daily staffing forms and the actual hours worked column was not completed, confirmed the facility had failed to complete the hours worked because they did not realize it was required. | 2020-09-01 |
| 2096 | 2096 | SIGNATURE HEALTHCARE OF GREENEVILLE | 445351 | 106 HOLT COURT | GREENEVILLE | TN | 37743 | 2018-08-23 | 623 | C | 0 | 1 | ZDQV11 | Based on review of the Emergency Transfer from Facility forms and interview, the facility failed to send the Ombudsman a notice of transfer or discharges for the months of April, May, and (MONTH) of (YEAR) for a total of 45 of 45 residents reviewed for emergency transfers. The findings include: Review of the Emergency Transfer from Facility forms dated 4/1/18 to 6/30/18 revealed 45 residents had emergency discharges from 4/1/18 - 6/30/18. Telephone interview with the Volunteer Assistant Ombudsman confirmed the Ombudsman had not been notified of acute emergency transfers from 4/1/18 to 6/30/18. Interview with the Business Office Manager on 8/22/18 at 10:03 AM, in the Business Office, confirmed emergency transfers from the facility reports had not been sent to the ombudsman from 4/1/18 to 6/30/18. | 2020-09-01 |
| 2281 | 2281 | PIGEON FORGE CARE & REHAB CENTER | 445382 | 415 COLE DRIVE | PIGEON FORGE | TN | 37863 | 2017-08-16 | 356 | C | 0 | 1 | VBZ511 | Based on review of the facility's Daily Staffing Form, observation, and interview, the facility failed to post daily staffing information. The findings included: Review of the facility's Daily Staffing Form revealed .Nursing Staffing Directly Responsible for Resident Care .Daily Posting of this information is required for nursing homes participating in Medicare and Medicaid. Observation on 8/14/17 at 8:30 AM, revealed the staffing information posted was dated 8/12/17. Observation and interview with the Administrator, in the facility lobby, on 8/14/17 at 9:00 AM, confirmed the staffing information had not been posted since 8/12/17. | 2020-09-01 |
| 2294 | 2294 | PIGEON FORGE CARE & REHAB CENTER | 445382 | 415 COLE DRIVE | PIGEON FORGE | TN | 37863 | 2018-09-19 | 842 | C | 0 | 1 | GSVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 Resident (#58) of 5 residents reviewed for unnecessary medications of 47 residents sampled. The findings included: Review of facility policy Medication Administration dated 5/2016, revealed .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .the space provided on the front of the MAR (medication administration record) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 9/1/18 to 9/30/18 revealed .Aripiprazole (antipsychotic medication) 10 mg (milligrams) .1 tablet orally daily . Medical record review of a MAR indicated [REDACTED]. Interview with the Director of Nursing on 9/19/18 at 7:05 PM, in the conference room, confirmed the facility failed to document why resident #58 missed 3 doses of Aripiprazole and the facility failed to follow facility policy. | 2020-09-01 |
| 2361 | 2361 | SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS | 445393 | 26 SECOND STREET | MONTEAGLE | TN | 37356 | 2017-03-29 | 372 | C | 0 | 1 | 3KL011 | Based on facility policy review, observation, and interview, the facility failed to dispose of garbage and refuse properly in 1 of 1 observations made of the outside dumpster area. The findings included: Review of a facility policy, Garbage and Trashcans revised 2/24/16 revealed .The dumpster area must be free of debris on the ground and the lid must be closed . Observation with the Dietary Manager (DM) on 3/27/17 at 10:25 AM, of the outside dumpster area, revealed two garbage bags exposed from under the lid of the dumpster with the lid closed down on the garbage bags. Continued observation revealed the followig items on the ground beside the dumpster: a). five disposable gloves. b). multiple pieces of paper. c). several slices of tomato, onion slices, and unidentifiable food particles. Interview with DM on 3/27/17 at 10:30 AM, outside at the dumpster area, confirmed the facility failed to properly maintain the dumpster area in a clean and sanitary manner. | 2020-09-01 |
| 2365 | 2365 | SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS | 445393 | 26 SECOND STREET | MONTEAGLE | TN | 37356 | 2018-05-24 | 577 | C | 0 | 1 | 63GM11 | Based on observation and interview, the facility failed to ensure the most recent survey results were readily accessible for all 96 residents residing in the facility. The findings included: Observation in the facility lobby on 5/22/18, at 11:00 AM, revealed a white binder with survey results from the facility's last annual survey on 3/27/17. Continued observation revealed no documentation of the facility's most recent survey results which had been conducted on 2/21/18. Interview with the Administrator on 5/22/18, at 11:05 AM, in the admissions office confirmed the facility did not include the most recent survey results in their survey results binder stating .It was my understanding it (the binder) was only to include the last annual survey . | 2020-09-01 |
| 2588 | 2588 | MCKENZIE HEALTH CARE CENTER | 445429 | 175 HOSPITAL DRIVE | MC KENZIE | TN | 38201 | 2017-11-15 | 170 | C | 0 | 1 | FZEQ11 | Based on resident rights and interview, the facility failed to ensure the residents were allowed to receive mail on Saturday. This practice could have affected all of the residents in the building receiving mail. The facility reported a census of 82. The findings included: The facility's Welcome Booklet documented, .Mail will be delivered to you each day . Interview with Resident #26 on 11/13/17 at 3:53 PM, in the resident's room, Resident #26 stated, .no mail on Saturday for the past 2 years .Resident Council has discussed mail not being delivered on Saturday .it would be nice to receive mail on Saturday . Interview with the Activities Director on 11/13/15 at 4:49 PM, in her office, the Activities Director was asked if residents received mail on Saturdays. The Activities Director stated, .they receive mail on Monday through Friday .the business office is closed on Saturday . Interview on 11/13/17 at 11:11 AM, outside the activity room, the Administrator was asked if the residents receive mail on Saturday. The Administrator stated .They were told and were ok not getting mail on Saturday . | 2020-09-01 |
| 2718 | 2718 | AHC DYERSBURG | 445446 | 1900 PARR AVENUE | DYERSBURG | TN | 38024 | 2019-07-24 | 732 | C | 0 | 1 | YH9R11 | Based on policy review, document review, and interview, the facility failed to complete daily staff postings for 105 of 105 days reviewed. The findings include: The facility's Nurse Staffing Posting Information policy dated 11/17 and revised 11/18 documented, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and to make staffing information readily available .The total number and the actual hours worked .per shift .Registered Nurses .Licensed Practical Nurses .Certified Nurse Aides .must include all nursing staff paid by the facility . Review of the facility's Daily Nurse Staffing forms dated 4/9/19 through 7/22/19 revealed there was no documentation of the total number and and actual hours staff worked each shift. Interview with the Staffing Coordinator on 7/24/19 at 3:41 PM, in the Staffing Office, the Staffing Coordinator confirmed the hours for licensed staff were not on the daily staff postings. The Staffing Coordinator was asked if she had included the total hours worked on the Daily Nurse Staffing form. The Staffing Coordinator stated, No, Ma'am . | 2020-09-01 |
| 2736 | 2736 | MISSION CONVALESCENT HOME | 445447 | 118 GLASS ST | JACKSON | TN | 38301 | 2017-11-21 | 156 | C | 0 | 1 | CXGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #16, 28, and 44) sampled residents reviewed for liability and appeal notices. The findings included: 1. The facility's Form Instructions for the Notice of Medicare Non-Coverage . policy documented, .A Medicare provider .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing .services .The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service of care is not being provided daily .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .The effective date coverage of your current Medicare Part A Service will end: 7-19-17 . There was no signature of the resident or resident representative indicating advance notice was provided. The Discharge Summary documented a discharge date of [DATE]. 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The NOTICE OF MEDICARE NON-COVERAGE form documented, .THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT .Skilled Rehab (Rehabilitation) .SERVICES WILL END: 9-15-17 . There was no signature of the resident or resident representative indicating advance notice was provided. Resident #28 was still residing at the facility, 4. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) documented, .T… | 2020-09-01 |
| 2809 | 2809 | SWEETWATER NURSING CENTER | 445456 | 978 HWY 11 SOUTH | SWEETWATER | TN | 37874 | 2017-12-13 | 881 | C | 0 | 1 | 4B6W11 | Based on facility policy review and interview the facility failed to implement an Antibiotic Stewardship Program for 80 of 80 residents currently on census. The findings included: Review of the Antibiotic Stewardship Policy revised 12/2016 revealed .It is the policy of this facility to follow an Antibiotic Stewardship program .The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events .Antibiotic Stewardship is part of our Infection Prevention & Control Program . Review of General Policies revised 2/2017 revealed .It shall be the responsibility of the Administrator/Executive Director, through the Infection Prevention & Control aspect of the Quality Assurance Performance Improvement Committee to assure that Infection Prevention & Control policies and procedures are implemented and followed . Interview with the Director of Nursing on 12/13/17 at 3:25 PM, in the chapel, confirmed she was not aware of the antibiotic stewardship program. Interview with the Nurse Consultant on 12/13/17 at 5:00 PM, outside of the chapel , confirmed the facility held a meeting to discuss the antibiotic stewardship program but had failed to implement the program. | 2020-09-01 |
| 2813 | 2813 | MADISONVILLE HEALTH AND REHAB CENTER | 445457 | 465 ISBILL RD | MADISONVILLE | TN | 37354 | 2019-05-20 | 842 | C | 1 | 0 | HYGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record reviews, observations, and interviews, the facility failed to store medical record documents designated for destruction in secure containers to prevent unauthorized access or use, for 3 Residents, (Residents #1, #2 and #3) of 3 residents reviewed for privacy, on 2 of 2 units. The findings included: Review of the facility policy, Retention of Records, revised 2006, revealed .inactive records .will be destroyed Review of the facility policy Protected Health Information (PHI), Management and Protection, revised (MONTH) 2014, revealed .it is the responsibility of all personnel who have access to resident and facility information .to ensure .information is managed and protected .to prevent unauthorized .disclosure . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations made throughout the facility during the initial tour revealed a lack of secure document destruction containers. Observations of the DON office and interview with the DON on 5/20/19 at 1:00 PM, revealed 18 card board boxes, with tops folded closed stored along the walls. All 18 boxes contained paper documents with protected health information for facility residents designated to be destroyed. The DON reported her office was locked when she was out of the building, but acknowledged the documents were not secured as stored, if her office door was left open while she was in the facility. The DON reported she had stored records awaiting destruction in her office since (MONTH) of 2019. Observation of the outside storage building and interview with the maintenance director on 5/20/19 at 1:20 PM, revealed 64 cardboard boxes of varying sizes stored there. E… | 2020-09-01 |
| 2981 | 2981 | LIFE CARE CENTER OF GRAY | 445479 | 791 OLD GRAY STATION ROAD | GRAY | TN | 37615 | 2018-10-31 | 921 | C | 1 | 1 | 7ZGX11 | > Based on facility policy review, observation and interview the facility failed to provide a safe, sanitary, and comfortable environment for all residents on 4 of 4 halls observed in the facility. The findings include: Review of the facility policy, Preventive Maintenance- Exhaust Fan Inspection, revealed .all exhaust fans will be inspected on a monthly basis or more often if needed . Observations made 10/29/18 through 10/31/18 during the survey revealed multiple rooms on 4 of 4 hallways with a large amount of dust and debris in the residents' bathroom exhaust fan vents. Interview with the Maintenance Director on 10/31/18 at 12:50 PM, in the hallway, confirmed the exhaust fan vents were in need of cleaning and were not on a set cleaning schedule. | 2020-09-01 |
| 3037 | 3037 | CORNERSTONE VILLAGE | 445483 | 2012 SHERWOOD DRIVE | JOHNSON CITY | TN | 37601 | 2017-05-17 | 356 | C | 0 | 1 | LW9W11 | Based on observation and interview, the facility failed to post the current resident census and nurse staffing data for 1 day of 3 days observed. The findings included: Observation on 5/8/17 at 12:32 PM, at the main entrance receptionist desk, revealed the facility staffing sheet posted was missing the current resident census and nurse staffing hours. Observation on 5/8/17 at 12:40 PM, at the upstairs nurse's station, revealed the facility staffing sheet posted was missing the current resident census and nurse staffing hours. Interview with Director of Nursing on 5/8/17 at 12:40 PM, at the upstairs nurse's station, confirmed the census and staffing sheets posted were incorrect. | 2020-09-01 |
| 3055 | 3055 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2017-03-07 | 372 | C | 0 | 1 | ENX011 | Based on observation and interview, the facility failed to dispose of garbage and refuse in a sanitary manner for 3 of 3 dumpsters observed. The findings included: Observation with the Assistant Dietary Manager on 3/5/17 at 9:30 AM, outside at the dumpster area, revealed: a). six blue disposable gloves. b). dried debris on the ground along the base of the middle dumpster c). multiple cigarette butts d). empty condiment packages, an empty potato chip bag, small pieces of paper, and a card board food package. All items were on the ground behind the dumpsters. Interview with the Assistant Dietary Manager on 3/5/17 at 9:35 AM, outside at the dumpster area confirmed the facility failed to dispose of garbage and refuse in a sanitary manner Interview with the Director of Clinical Services on 3/6/17 at 11:19 AM, in the conference room confirmed the dumpster area had not been maintained in a sanitary manner. | 2020-09-01 |
| 3056 | 3056 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2019-04-24 | 657 | C | 0 | 1 | OQ0X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide documentation of Certified Nurse Aide (CNA) participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) of 37 residents reviewed. The findings include: Review of the facility policy Clinical Comprehensive Care Plans Policy, dated 3/1/16 revealed .utilize information gathered .to develop, review and revise the Resident's Comprehensive Plan of Care .the Care Planning/Interdisciplinary Team .develops and maintains a comprehensive plan of care .that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions .include, but not limited to .Nursing Assistants . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/31/18 and 1/9/19 revealed no documentation of CNA participation for Resident #7. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #8. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/24/19 revealed no documentation of CNA participation for Resident #18. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/8/18 and 2/11/19 revealed no documentation of CNA participation for Resident #24. Medical record review revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 1/22/19 revealed no … | 2020-09-01 |
| 3066 | 3066 | STONERIDGE HEALTH CARE, LLC | 445486 | 5121 GREER ROAD | GOODLETTSVILLE | TN | 37072 | 2018-04-25 | 881 | C | 0 | 1 | 1BNF11 | Based on infection control review and interview, the facility failed to develop and implement an Antibiotic Stewardship program. The findings included: Interview and review of the facility infection control program with the Assistant Director of Nursing (ADON) on 4/25/18 at 8:00 AM, in the conference room revealed there was no documentation the facility had an Antibiotic Stewardship Program. Interview with the ADON confirmed the facility had not developed an Antibiotic Stewardship Program. | 2020-09-01 |
| 3109 | 3109 | MCKENDREE VILLAGE | 445491 | 4347 LEBANON ROAD | HERMITAGE | TN | 37076 | 2017-04-26 | 253 | C | 0 | 1 | SXEG11 | Based on observation and interview the facility failed to provide and maintain a clean, safe, comfortable and homelike environment in resident's rooms and resident's shared common areas for 2 of 3 units observed in the facility. The findings included: Observations of resident' rooms during the environmental tour on 4/26/17 at 9:35AM with the Maintenance Director, revealed the following: 1. Rooms 177 East (E), 260E, 267E and 282E, had over-the-bed tables with missing areas of veneer which allowed the sharp edges of the wood to be exposed. 2. Room 177E had several brown stains on the wall near the bed and bathroom. 3. The 2 East Lounge/TV area had a black over-stuffed recliner with several large areas on the arms of the chair with missing vinyl exposing the cloth material beneath. A brown recliner in this same area had two large holes in the vinyl on the right side of the chair exposing the material beneath and prevented the chairs from being sanitized after use. 4. Room 266E had a leaky bathroom faucet that continued to leak water even after both handles were turned to the off position. The Maintenance Director confirmed at this time that the faucet could not be shut off and should be replaced. 5. Rooms 267E and 260E had bathroom toilet risers with areas were the paint had been chipped exposing the bare metal beneath, and prevented the resident's equipment from being sanitized effectively after use. 6. Rooms177E, 267E-Bed A, and 263E- Bed A, had drywall behind the head of the bed that was marred and gouged. In the residents' bathroom for rooms 266E and 269E, the drywall corner wall edges were gouged and had areas of missing cove base. The drywall below the air conditioner unit in room 266E was gouged and had an area that was missing drywall. Black marks were observed along the walls in room 266E-Bed [NAME] 7. Room 267E-Bed A, had a blue floor mat with a tear in the corner of the vinyl exposing the foam beneath, thus preventing the item from being sanitized after use. 8. Room 269E and 267E, the closet doors were of… | 2020-09-01 |
| 3200 | 3200 | THE MEADOWS | 445496 | 8044 COLEY DAVIS ROAD | NASHVILLE | TN | 37221 | 2019-06-05 | 607 | C | 0 | 1 | T6TK11 | Based on facility policy review, record review and interview, the facility failed to have abuse registry checks for 8 of 8 employee personnel files reviewed. The findings include: Facility policy review, Personnel File Maintenance, revised 4/1/15, revealed .Specific documents relating to individuals' employment with the company are maintained in their personnel files. The following may be maintained in a separate file: company and/or state required criminal background check report . Record review on 6/5/19 at 12:00 PM revealed 8 employee personnel files did not obtain abuse registry checks until 6/4/19. Interview with the Payroll/Bookkeeper on 6/5/19 at 3:10 PM in her office confirmed it was a miscommunication problem between the staffing coordinator and her (payroll/bookkeeper) as to who was to complete and place the abuse registry checks in the personnel files. Interview with the Administrator on 6/5/19 at 3:30 PM in his office confirmed confirmed 8 of 8 records reviewed did not contain abuse registry checks prior to the survey. | 2020-09-01 |
| 3324 | 3324 | GOOD SAMARITAN SOCIETY - FAIRFIELD GLADE | 445506 | 100 SAMARITAN WAY | CROSSVILLE | TN | 38558 | 2019-11-14 | 655 | C | 0 | 1 | 69HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide evidence of documentation in the medical record indicating a Baseline Care Plan summary was given to the resident and/or resident representative for 6 Residents (#1, #16, #21, #22, #34, and #195) and failed to develop a Baseline Care Plan timely for 1 Resident (#16) of 6 residents reviewed for Baseline Care Plans. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 11/1/19 revealed no documented evidence Resident #1 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 5/21/19 revealed no documented evidence Resident #16 and/or the resident representative had received a summary of the Baseline Care Plan. Continued review revealed the Baseline Care Plan was dated 6 days after the admitted . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/24/18 revealed no documented evidence Resident #21 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 9/23/19 revealed no documented evidence Resident #22 and/or the resident representative had received a summary of the Baseline Care Plan. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 10/14/19 revealed no documented evidence Resident #34 and/or the resident representative had received a … | 2020-09-01 |
| 3498 | 3498 | LAKESHORE HEARTLAND | 445526 | 3025 FERNBROOK LANE | NASHVILLE | TN | 37214 | 2017-06-27 | 356 | C | 0 | 1 | 1W5Z11 | Based on observation and interview, the facility failed to ensure staffing was posted correctly on 1 of 3 days. The findings included: Observation on 6/25/17 at 10:10 AM, in the front lobby, revealed the daily staff posting dated 6/25/17 for the 6 AM to 6 PM shift indicated 1 Registered Nurse (RN), 2 Licensed Practical Nurses (LPN) and 8 Certified Nurse Technicians (CNT) were working. Observation and interview with the Director of Nursing (DON) on 6/25/17 at 10:10 AM, in the front lobby, confirmed the posted staffing was incorrect. Continued interview revealed 3 LPN's and 6 CNT's were on duty for the 6 AM to 6 PM shift. | 2020-09-01 |
| 3640 | 3640 | PALMYRA HEALTH AND REHABILITATION | 445184 | 2727 PALMYRA RD | PALMYRA | TN | 37142 | 2017-05-25 | 156 | C | 0 | 1 | K3HH11 | Based on medical record review and interview, the facility failed to provide appropriate liability and appeal notices for 3 of 3 (Resident #8,17 and 28) sampled residents reviewed for liability and appeal notices. The findings included: Medical record review revealed Resident #8 had a therapy end date of 5/7/17 with a documented telephone notification on 5/4/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #8's responsible party (RP). Medical record review revealed Resident #17 had a therapy end date of 2/10/17 with a documented telephone notification on 2/5/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #17's responsible party. Medical record review revealed Resident #28 had a therapy end date of 3/13/17 with a documented telephone notification on 3/7/17. The facility was unable to provide documentation that the liability notice had been mailed to Resident #28's responsible party. Interview with the Business Office Manager on 5/23/17 at 4:26 PM, in the conference room, the Business Office Manager stated, I failed to tell you that we did not send letters to those family members. The Business Office Manager was asked if she could provide any proof that the letters were sent. The Business Office Manager stated, No ma'am they were never sent. Interview with the Administrator on 5/23/27 at 4:45 PM, in the conference room, the Administrator stated, .no letters were mailed out . Interview with the Social Services Director on 5/23/17 at 5:48 PM, in the Administrator's office, the Social Services Director was asked if Resident #28 was his own patient representative because his notification letter stated he refused to sign. The Social Services Director stated, No his ex-wife is his RP. The Social Services Director was asked if Resident #28's RP should have been the person receiving the liability appeal letter. The Social Services Director stated, Yes. | 2020-04-01 |
| 3641 | 3641 | PALMYRA HEALTH AND REHABILITATION | 445184 | 2727 PALMYRA RD | PALMYRA | TN | 37142 | 2017-05-25 | 160 | C | 0 | 1 | K3HH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the facility's Detail Admission/Discharge Report, and interview, the facility failed to refund 2 of 8 (Resident #20 and 65) sampled residents' account balances within 30 days of death. The findings included: 1. The facility's FINANCIAL AGREEMENT policy documented, .If a Resident that has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual or probate jurisdiction administering the Resident's estate or other entity as required by State law or regulation . 2. Review of the facility's Detail Admission/Discharge Report revealed the following: a. Resident #20 expired on [DATE] and the account balance was not refunded until [DATE], a total of 80 days later. b. Resident #65 expired on [DATE] and the account balance was not refunded until [DATE], a total of 81 days later. Telephone interview with the Accounts Receivable Manager on [DATE] at 8:37 AM, the Accounts Receivable Manager was asked how long it should take to refund the resident's account balance after the resident expired. The Accounts Receivable Manager stated, We try to do that in 30 days .I know there are some that have been late. The Accounts Receivable Manager was asked if it was acceptable to not refund the residents' account balance within 30 days after the resident expired. The Accounts Receivable Manager stated, No ma'am. | 2020-04-01 |
| 3812 | 3812 | HOLSTON MANOR | 445295 | 3641 MEMORIAL BLVD | KINGSPORT | TN | 37664 | 2016-12-14 | 356 | C | 0 | 1 | RJIW11 | Based on observation and interview the facility failed to post accurate staffing data and record the census for 12/12/16. The findings included: Observation of posted staffing data on 12/12/16 at 9:50 AM, revealed staffing was posted as follows: a. Registered Nurses (RN) 4 b. Licensed Practical Nurses (LPN) 9 Continued observation revealed the census for 12/12/16 was not posted. Interview with the Director of Nursing (DON) on 12/12/16 at 10:15 AM, in the DON's office revealed there were 3 RN's and 6 LPN's currently currently working and confirmed the staffing data posted was not accurate and did not reflect the current census. | 2020-02-01 |
| 3898 | 3898 | NHC HEALTHCARE, KNOXVILLE | 445098 | 809 EAST EMERALD AVE | KNOXVILLE | TN | 37917 | 2016-10-20 | 167 | C | 0 | 1 | N3NC11 | Based on observation and interview, the facility failed to label and place the state survey results in a readily accessible location for resident use. The findings included: Observation of the first floor lobby on 10/19/16 at 10:00 AM, revealed the state survey results were in an unlabeled basket attached to the wall above the chair rail. Further observation revealed the first floor contained the kitchen, bookkeeping, business office, and laundry room. Interview with the Administrator on 10/19/16 at 1:25 PM, on the first floor, confirmed the facility failed to label and place the results of the state survey in a location readily accessible to residents. | 2020-01-01 |
| 3909 | 3909 | NHC HEALTHCARE, COLUMBIA | 445109 | 101 WALNUT LANE | COLUMBIA | TN | 38401 | 2017-02-08 | 356 | C | 0 | 1 | 7T7F11 | Based on observation and interview, the facility failed to post the nurse staffing information on a daily basis for 2/4/17 and 2/5/17. The findings included: Observation on 2/6/17 at 9:05 AM in the front lobby of the facility, during the initial tour, revealed the facility failed to post the nurse staffing information for 2/6/17. Interview with Licensed Practical Nurse (LPN) #1 on 2/6/17 at 9:20 AM at the AB nurse's station confirmed the nurse staffing information was not posted for 2/4/17 and 2/5/17. Continued interview with LPN #1 confirmed the daily nurse staffing information for 2/6/17 was posted by 10:00 AM. Interview with the Director of Nursing (DON) on 2/7/17 at 1:30 PM in the classroom confirmed the facility failed to post the nurse staffing information for 2/4/17 and 2/5/17. | 2020-01-01 |
| 3992 | 3992 | NHC HEALTHCARE, SMITHVILLE | 445116 | 825 FISHER AVE P O BOX 549 | SMITHVILLE | TN | 37166 | 2016-10-04 | 356 | C | 0 | 1 | SH5D11 | Based on observation and interview, the facility failed to post accurate nurse staffing information in 1 of 3 observations. The findings included: Observation on 10/2/16, at 9:32 AM, in the main entrance foyer, revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for 9/29/16, and had not been updated to reflect current nursing staff in the facility on 10/2/16. Interview with Licensed Practical Nurse #1, on 10/2/16 at 9:35 AM, in the main entrance lobby, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate staffing. | 2019-11-01 |
| 4075 | 4075 | SUMMIT VIEW OF ROCKY TOP | 445259 | 204 INDUSTRIAL PARK RD | ROCKY TOP | TN | 37769 | 2016-07-20 | 356 | C | 0 | 1 | VGPG11 | Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 7/18/16 at 9:15 AM, in the facility's main entrance revealed the nurse staffing sheet posted was dated 7/15/16. Interview with the Director of Nursing on 7/18/16 at 9:18 AM, in the facility's main entrance confirmed the nurse staffing sheet posted was not for the current date. | 2019-11-01 |
| 4081 | 4081 | CUMBERLAND VILLAGE GENESIS HEALTHCARE | 445276 | 136 DAVIS LANE | LAFOLLETTE | TN | 37766 | 2017-01-11 | 356 | C | 0 | 1 | XT5X11 | Based on observation and interview, the facility failed to post staffing in a prominent place readily accessible to residents and visitors. The findings included: Observation on 1/9/17, at 9:40 AM at the back hall corridor, between the 100 and 200 Hall nurses station, revealed the staffing information posting. The staffing posting was not in a prominent place readily accessible to residents and visitors. Interview with the Assistant Director of Nursing on 1/11/17 at 2:19 PM in front of the staffing posting on the back hall corridor, between the 100 and 200 Hall nurses station, confirmed the staffing information was not in a prominent place readily accessible to residents and visitors | 2019-11-01 |
| 4175 | 4175 | LEWIS COUNTY NURSING AND REHABILITATION CENTER | 445430 | 119 KITTRELL ST, PO BOX 129 | HOHENWALD | TN | 38462 | 2017-01-19 | 156 | C | 0 | 1 | ZHG411 | Based on record review and interview, the facility failed to provide the appropriate liability and appeal for 1 of 4 (Resident #74) sampled residents reviewed for liability and appeal notices. The findings included: Review of the advanced beneficiary notices on 1/20/17 at 6:40 PM, in the Admissions Office, the facility was unable to provide an advanced beneficiary notice for Resident #74. Interview with the Social Services Director (SSD), on 1/18/17 at 6:48 PM, in the Admissions Office, the SSD stated, .I couldn't find the letter (advanced beneficiary letter) for (Named resident) .I think she went long term care .I dropped the ball on it .she had additional days left . | 2019-11-01 |
| 4254 | 4254 | THE WATERS OF UNION CITY , LLC | 445138 | 1105 SUNSWEPT DR | UNION CITY | TN | 38261 | 2016-09-29 | 356 | C | 0 | 1 | 1KSC11 | Based on policy review, observation and interview, the facility failed to post current and accurate nurse staffing information at the beginning of each shift during 3 of 3 (9/18/19, 9/19/16 and 9/23/16) days of observing the posted nursing staff information. The findings included: 1. Review of the Nursing Staff Hours policy documented Nursing Hours will be posted in accordance with state and federal Regulations .The following information shall be posted on a daily basis at the beginning of each shift .The number and actual hours worked by licensed and unlicensed staff responsible for resident care, including RNs (Registered Nurses), LPNs (Licensed Practical Nurses) and CNAs (Certified Nursing Assistants). 2. Observations during the initial tour of the facility on Sunday, 9/18/19 at 2:10 PM, revealed the nurse staffing information was posted in the window of the business office. The posting was dated for Friday, 9/16/16 and included all three shifts and the total census. Observations on 9/18/16 at 3:45PM and 9/18/16 at 6:30 PM revealed the posted information for Friday, 9/16/16, remained posted. Observations on Sunday, 09/18/16 at 11:30 PM revealed the nursing staff information posted in the window of the business office was dated for Sunday, 9/18/16, and included all three shifts and the total census. Observations upon entrance into the facility on Monday, 9/19/16 at 9:25 AM, revealed the nurse staffing information was posted in the window of the business office. The staffing information posted was dated Sunday, 9/18/16, and included all three shifts and the total census. Observations of the nursing staff information posted in the business office window on Monday, 9/19/16 at 11:55 AM, revealed nursing staff information dated for Sunday, 9/18/16. The Regional Nurse exited the Administrators office to point out the Staff Posting was taped to the wall next to the facility license. The Regional Nurse stated she placed it there that morning because the business office was not opened. Surveyors reviewed the the same wa… | 2019-10-01 |
| 4305 | 4305 | SPRING GATE REHAB & HEALTHCARE CENTER | 445220 | 3909 COVINGTON PIKE | MEMPHIS | TN | 38135 | 2016-09-30 | 203 | C | 0 | 1 | H2DS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Title 42 (42) Code of Federal Regulations (C.F.R.), 483.12 Admission, Transfer and Discharge Rights, medical record review, and interview, the facility failed to include the location to which the resident was transferred or discharged on the 30 day notice of discharge for 6 of 6 (Resident # 58, 71, 89, 138, 156 and 188) sampled residents reviewed for involuntary discharge. The findings included: 1. The 42 C.F.R. 483.12 (a) . documented, .(4) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .(6) Contents of the notice. The written notice specified in paragraph (a) (4) of this section must include the following .(iii) The location to which the resident is transferred or discharged . 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 16, (YEAR) documented, .(Named Resident #58) will be transferred to another skilled nursing facility &/or care home placement . The FINAL ADMINISTRATIVE ORDER dated (MONTH) 26, (YEAR) documented, .it is determined that (Named Nursing Home) may not involuntarily transfer or discharge Respondent at this time. This determination is based on the following findings of fact and conclusions of law .8. The discharge notice does not contain a discharge location . 3. Medical record review revealed Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A notice of discharge date d (MONTH) 23, (YEAR) documented, .Re: (Named Resident #71) .The Resident or Responsible Party has been informed that they must make alternative living arrangements on or before (MONTH) 23, (YEAR) . Resident #71 has appeal… | 2019-10-01 |
| 4347 | 4347 | MABRY HEALTH CARE | 445272 | 1340 N GRUNDY QUARLES HWY P O BOX 7 | GAINESBORO | TN | 38562 | 2016-10-13 | 356 | C | 1 | 0 | 0FBG11 | > Based on observation and interview, the facility failed to post the current nurse staffing information in a prominent place readily accessible to residents and visitors during 2 days of the survey. The findings included: Observation upon entering the facility on 10/5/16 at 11:30 PM and on 10/6/16 at 7:45 AM revealed the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. Interview with Director of Nursing on 10/6/16 at 12:15 AM at the C Hall Nurses Station confirmed the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. | 2019-10-01 |
| 4400 | 4400 | LAURELWOOD HEALTHCARE CENTER | 445413 | 200 BIRCH ST | JACKSON | TN | 38301 | 2016-10-27 | 170 | C | 0 | 1 | 6DH211 | Based on policy review and interview, it was determined the facility failed to ensure residents' mail was promptly delivered on Saturdays. The facility reported a current census of 59 residents. The findings included: The facility's Attachment B - Resident Rights - Federal policy documented, .I. Mail. The resident has the right to privacy in written communication, including the right to: 1. Send and promptly receive mail that is unopened . Interview with the Resident #40 in her room on 10/24/16 at 10:10 AM, Resident #40 was asked if the mail is delivered unopened and on Saturdays. Resident #40 stated, No, and it is opened to make sure it is OK . Interview on 10/27/16 at 9:29 AM, in the Social Worker office, the Social Worker (SW) was asked if residents receive mail unopened on Saturdays. The SW stated, No, the mail is gone through to make sure it's ok, then its passed out on Monday . Interview on 10/27/16 at 11:04 AM, in the day room, the Activity Director (AD) was asked about how residents in the facility receive mail. The AD stated, One of my duties is collecting the mail and distributing it to residents .everyday I check if they have mail, and I will distribute it. The AD was asked why residents do not receive mail on Saturday. The AD stated, I am not here on Saturday, so there is nobody to do it . Interview on 10/27/16 at 11:11 AM, in the Business office, the Human Resources Person (HRP) was asked about the residents receiving mail on Saturdays. The HRP stated, We are not here on Saturday. Saturday's mail gets distributed on Monday. Interview on 10/27/16 at 11:40 AM, in the day room, the Administrator was asked if the residents receive mail unopened on Saturday. The Administrator said, No. | 2019-10-01 |
| 4497 | 4497 | STARR REGIONAL HEALTH & REHABILITATION | 445277 | 886 HWY 411 NORTH | ETOWAH | TN | 37331 | 2016-06-03 | 241 | C | 0 | 1 | 3OTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a homelike environment and to maintain dignity and respect observed during 2 of 2 dining experiences and in 2 of 2 dining rooms. The findings included: Review of facility policy, Meal Service, dated 6/1/08 revealed .Meals are served in a manner that enhances each patient/resident's dignity and in an environment that is as home-like as possible . Observation during lunch dining on 5/31/16 at 12:30 PM revealed lunch was served with the plates and other items left on the trays. Continued observation revealed milk and juice were not poured into glassware but was served in the cartons with straws for 8 residents. Observation during breakfast dining on 6/1/16 at 8:00 AM revealed breakfast was served with the plates and other items left on the trays. Continued observation revealed the milk was not poured into glassware but was served in the cartons with straws for 7 residents, juice was not poured into glassware but was served in the cartons with straws for 9 residents and pre-packaged cereal was served to 4 residents. Observation during lunch dining on 5/31/16 at 12:00 PM, in the A wing dining room revealed lunch was served with the plates and other items left on the trays. Continued observation revealed milk, juice, and ensure, were not poured into glassware but was served in the cartons with straws for 20 residents. Continued observation revealed 1 resident was served a peanut butter and jelly sandwich in a clear plastic to go container. Observation during breakfast dining on 6/1/16 at 8:00 AM, in the A wing dining room revealed breakfast was served with the plates and other items left on the trays. Continued observation revealed the milk, juice, and ensure, was not poured into glassware but was served in the cartons with straws for 14 residents. Continued observation revealed sausage gravy, fried eggs, and boiled eggs were served in Styrofoam bowls. Conti… | 2019-09-01 |
| 4513 | 4513 | ROGERSVILLE CARE & REHABILITATION CENTER | 445359 | 109 HWY 70 NORTH | ROGERSVILLE | TN | 37857 | 2016-07-07 | 356 | C | 0 | 1 | JVL711 | Based on observation and interview, the facility failed to ensure the Nurse Staffing data posted was correct. The findings included: Observation during the initial tour on 7/5/16 at 10:30 AM, inside the main entrance revealed the Nurse Staffing posted listed 8 Registered Nurses (RNs) working on the day shift. Further observation revealed 5 RNs were working direct care. Interview with the Director of Nursing (DON) on 7/7/16 at 9:40 AM, in the DON's office confirmed there were only 5 RNs working direct care and the Nurse Staffing posted was incorrect. | 2019-09-01 |
| 4696 | 4696 | GRACELAND REHABILITATION AND NURSING CARE CENTER | 445331 | 1250 FARROW ROAD | MEMPHIS | TN | 38116 | 2016-05-11 | 159 | C | 0 | 1 | J48A11 | Based on policy review, review of residents' balances, and interview, the facility failed to ensure residents receiving Medicaid funding balances did not exceeded the Supplemental Security Income (SSI) limit for 17 of 163 (Residents #4, 28, 64, 91, 93, 102, 104, 111, 123, 142, 160, 176, 178, 182, 185, 196, and 198) residents with accounts in the facility during the first quarter of (YEAR) as of (MONTH) 31, (YEAR). The findings included: 1. The facility's Personal Funds policy documented, POLICY: To provide uniform guidelines to manage the finances of residents who choose to have the facility manage their personal funds .Resource Limit Notification Residents who receive Medical Assistance benefits must maintain a resident fund balance below the Medical Assistance resource limit. The facility will notify a Medicaid resident if his or her account balance is within Two Hundreds Dollars ($200.00) of the allowable resource limit ($2000.00). Resident fund accounts exceeding the resource limit may cause the Resident to be ineligible for Medical Assistance benefits . 2. Review of the account balances as of 3/31/16 revealed the following balances: a. Resident #4 with a balance of $2,202.36. b. Resident #28 with a balance of $5,439.54. c. Resident #64 with a balance of $2,190.47. d. Resident #91 with a balance of $2,241.35. e. Resident #93 with a balance of $2,639.25. f. Resident #102 with a balance of $2,768.87. g. Resident #104 with a balance of $3,149.50. h. Resident #111 with a balance of $2,402.21. i. Resident #123 with a balance of $2,565.45. j. Resident #142 with a balance of $2,543.93. k. Resident #160 with a balance of $2,498.89. l. Resident #176 with a balance of $2,124.56. m. Resident #178 with a balance of $3,312.09. n. Resident #182 with a balance of $3,293.04. o. Resident #185 with a balance of $2,582.65. p. Resident #196 with a balance of $2,147.18. q. Resident #198 with a balance of $2,481.97. 3. Interview with the Business Office Manager (BOM) on 5/11/16 at 5:00 PM, in the BOM office, the BOM was asked abou… | 2019-08-01 |
| 4740 | 4740 | ISLAND HOME PARK HEALTH AND REHAB | 445476 | 1758 HILLWOOD DRIVE | KNOXVILLE | TN | 37920 | 2016-06-15 | 356 | C | 0 | 1 | 0U3911 | Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 6/13/16 at 5:30 AM, in the facility front hall revealed the nurse staffing sheet was dated 6/10/16. Interview with the Assistant Administrator on 6/13/16 at 5:35 AM, in the facility front hall confirmed the nurse staffing sheet posted was not for the current date. | 2019-08-01 |
| 4857 | 4857 | ETOWAH HEALTH CARE CENTER | 445422 | 409 GRADY ROAD, PO BOX 957 | ETOWAH | TN | 37331 | 2016-05-04 | 372 | C | 0 | 1 | F15O11 | Based on observation and interview, the facility failed to dispose of garbage properly. The findings included: Observation on 5/2/16 at 9:45 AM, with the Certified Dietary Manager and facility Maintenance Director present revealed the facility trash container top lids were open with approximately 20 trash bags over the top of the trash container. Interview with Certified Manager and facility Maintenance Director on 5/2/16 at 9:45 AM, by the facility trash container confirmed the trash container lids were open with trash over the top edge of the container. Continued interview revealed the facility only had one trash container. Further interview revealed the trash was picked up Monday through Friday only. Interview revealed the trash overflow occurred after the Friday pick-up through the Monday morning pick-up. | 2019-07-01 |
| 4891 | 4891 | THE WATERS OF JOHNSON CITY, LLC | 445487 | 140 TECHNOLOGY LANE | JOHNSON CITY | TN | 37604 | 2016-05-18 | 356 | C | 0 | 1 | NE5911 | Based on observation and interview, the facility failed to post the current nurse staffing data for 1 of 3 days of the survey. The findings included: Observation on 5/16/16 at 7:15 PM of the Nursing Staffing form, posted across from the Administrator's office, revealed the form was dated 5/15/16. Interview with the Administrator on 5/16/16 at 7:15 PM in the Administrator's office confirmed the facility failed to post the 5/16/16 Nursing Staff form. | 2019-07-01 |
| 4914 | 4914 | NHC HEALTHCARE, SOMERVILLE | 445119 | 308 LAKE DRIVE, PO BOX 550 | SOMERVILLE | TN | 38068 | 2016-04-20 | 156 | C | 0 | 1 | 750M11 | Based on review of a Survey and Certification Letter, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #15, 59 and 87) sampled residents reviewed for liability and appeal notices. The findings included: 1. The Survey and Certification Letter Ref (reference): S&C (Survey and Certification) - 09-20 dated 1/9/09 documented, .Notice Delivery to Representatives . Providers are required to develop procedures to use when the beneficiary is incapable . and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact . provider should telephone the representative . Confirm telephone contact by written notice mailed on that same date . 2. The Notice of Medicare Non-Coverage form for Resident #15 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & (and) Therapy) Services Will End: 1/19/16 . Telephone contact was made with the resident's responsible party on 1/14/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 3. The Notice of Medicare Non-Coverage form for Resident #59 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 11/6/2015 . Telephone contact was made with the resident's responsible party on 11/2/15. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 4. The Notice of Medicare Non-Coverage form for Resident #87 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 3/09/2016 . Telephone contact was made with the resident's responsible party on 3/4/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 5. Interview with the Social Worker (SW) on 4/20/16 at 11:00 AM, in the Social Worker's office, the SW was asked if the date on the top of the page wa… | 2019-06-01 |
| 5117 | 5117 | WILLOWS AT WINCHESTER CARE & REHABILITATION CENTER | 445319 | 32 MEMORIAL DRIVE | WINCHESTER | TN | 37398 | 2016-04-04 | 356 | C | 0 | 1 | 1YMP11 | Based on observation and interview, the facility failed to post the nurse staffing data for public access on 3/28/16. The findings included: Observation during the initial tour of the facility on 3/28/16 at 7:30 PM revealed nurse staffing data was not posted for public access. Interview with Licensed Practical Nurse (LPN) #1 on 3/28/16 at 7:51 PM at the nurse's station confirmed staffing was not posted for public access. Interview with the Director of Nursing ( DON) on 3/28/16 at 7:55 PM in the front hallway stated the nurse staffing data had not been posted for 3/28/16 and should have been. Further interview confirmed the facility had failed to post the nurse staffing data for public access. | 2019-05-01 |
| 5262 | 5262 | LIFE CARE CENTER OF CENTERVILLE | 445252 | 112 OLD DICKSON RD | CENTERVILLE | TN | 37033 | 2016-03-10 | 160 | C | 0 | 1 | GRJK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of written checks, medical record review and interview, the facility failed to refund to the deceased resident's estate the balance of the resident's account within 30 days for 2 of 3 (Resident #130 and 131) residents reviewed with refunds. The findings included: 1. The facility's Recommended Procedures and TIPS/Daily-Monthly RESIDENT FUNDS MANAGEMENT SYSTEM (RFM) policy documented, .Refunds should always be withdrawn timely and sent promptly to the appropriate party . 2. Medical record review revealed Resident #130 expired on [DATE]. Review of a check dated [DATE] documented, pay to the order of (Named Funeral Home). 3. Medical record review revealed Resident #131 expired on [DATE]. Review of a check dated [DATE] documented, Refund from Trust Fund. Interview with the Receptionist on [DATE] at 4:00 PM, in the conference room, the Receptionist verified the refunds were not done within the 30 days as required. | 2019-04-01 |
| 5364 | 5364 | JEFFERSON CITY HEALTH AND REHAB CENTER | 445246 | 283 W BROADWAY BLVD | JEFFERSON CITY | TN | 37760 | 2016-02-03 | 372 | C | 0 | 1 | FX2E11 | Based on policy review, observation, and interview the facility failed to dispose of garbage and refuge properly and maintain a clean environment around the dumpsters and recycled dumpster bin in 1 of 1 dumpster areas observed. The findings included: Review of facility policy, Solid Waste Disposal, undated revealed .Porter .When necessary, empty trash bin into dumpster .Monitor dumpster area for cleanliness . Observation with the Dietary Manager (DM) on 2/1/16 at 9:21 AM, of the dumpster area revealed over 100 cigarette butts, numerous paper and plastic products on the ground surrounding all 4 dumpsters and the 1 recycled dumpster bin. Interview with the DM on 2/1/16 at 9:22 AM, at the dumpster area confirmed the facility failed to dispose of the garbage and refuge properly and failed to maintain a clean environment in the area surrounding the dumpsters and the recycled dumpster bin. | 2019-03-01 |
| 5441 | 5441 | HILLVIEW HEALTH CENTER | 445464 | 1666 HILLVIEW DRIVE | ELIZABETHTON | TN | 37643 | 2016-03-02 | 372 | C | 0 | 1 | WJ4911 | Based on observation and interview the facility failed to maintain a clean and sanitary area around the dumpsters to ensure garbage and refuse were disposed of properly. The findings included: Observation with the Dietary Manager on 3/2/16 at 9:52 AM, of the outside dumpsters revealed the area surrounding 2 dumpsters was littered with soft drink bottles, rubber gloves, paper items and multiple cigarettes butts. Interview with the Dietary Manager on 3/2/16 at 10:01 AM, in the kitchen, confirmed the facility failed to dispose of garbage properly. | 2019-03-01 |
| 5485 | 5485 | CLAIBORNE AND HUGHES HLTH CNTR | 445157 | 200 STRAHL STREET | FRANKLIN | TN | 37064 | 2015-08-27 | 356 | C | 0 | 1 | 66JE11 | Based on policy review, observation and interview, the facility failed to post the actual working hours of the nursing staff for 4 of 4 (8/24/15, 8/25/15, 8/26/15 and 8/27/15) days of the survey. The facility identified a census of 95 residents. The findings included: 1. Review of the facility's Staffing Hours Posted policy revealed, nursing hours will be posted daily in an area viewable by the public. 2. Observation on 8/24/15 at 1:20 PM, revealed the nurse staffing data located in a case on the hallway by the front entrance. The facility did not post the actual working hours of the nursing staff. 3. Observation on 8/25/15 at 1:15 PM, on 8/26/15 at 8:35 AM, and on 8/27/15 at 8:50 AM, revealed the facility did not post the actual working hours of the nursing staff. 4. Interview with Administrative Staff A on 8/26/15 at 9:25 AM, revealed the facility did not post the actual working hours of the nursing staff. The facility failed to post the actual working hours of the nursing staff as required. | 2019-02-01 |
| 5502 | 5502 | CONCORDIA TRANSITIONAL CARE AND REHAB-MARYVILLE | 445245 | 1012 JAMESTOWN WAY | MARYVILLE | TN | 37803 | 2016-01-13 | 372 | C | 0 | 1 | SCNY11 | Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris, for 4 of 4 dumpsters observed. The findings included: Review of facility policy, Waste Management for Foodservice, dated 2/28/14 revealed .In the dumpster area: confirm lid or door is closed on the dumpster .do not leave any trash along side .of the dumpster . Observation with the Dietary Manager on 1/11/16 at 1:30 PM, at the dumpster area revealed 4 dumpsters with trash on the ground around the dumpsters including the following: 4 disposable gloves discarded inside out, straws, straw covers, cups, cup lids, drink cans, with other paper and plastic trash. Continued review revealed 1 dumpster door open. Interview with the Dietary Manager on 1/11/16, at 1:30 PM, at the dumpster area confirmed the facility failed to maintain the cleanliness of the dumpster area. | 2019-02-01 |
| 5615 | 5615 | WOODLAND TERRACE CARE AND REHAB | 445205 | 8249 STANDIFER GAP ROAD | CHATTANOOGA | TN | 37421 | 2016-01-05 | 254 | C | 1 | 0 | 8BJL11 | > Based on observation and interview, the facility failed to maintain supplies of clean bath linens sufficient to meet resident needs for 2 of 2 linen storage closets and 6 of 6 clean linen storage carts, on 2 of 2 wings in the facility. The findings included: Observations of the physical environment on 12/3/15 from 12:50 PM to 3:00 PM throughout the facility revealed 2 of 2 clean linen rooms and 6 of 6 clean linen carts on 2 of 2 wings of the facility were devoid of clean towels, wash cloths, and gowns available for resident use (0 clean items were present in any of the areas observed). Observation of the Laundry Room with the Laundry Manager on 12/3/15 at 2:00 PM revealed one 44 gallon plastic barrel contained soiled sheets, towels, wash cloths, and gowns. Continued observation of Dryer Unit #3 revealed the unit was full of clean bed sheets, gowns, bed pads, towels and washcloths. Continued observation of Washer Unit #1 revealed the washer was full of towels. Staff interviews conducted on both wings of the facility between 2:05 PM and 2:20 PM revealed 5 of 5 Certified Nursing Assistants interviewed (CNAs #1, #3, #4, #5, #6) and 3 of 3 Licensed Practical Nurses (LPNs #1, #2, #3) interviewed reported the facility ran out of clean linens on every shift daily and staff members were known to hide clean linens as they became available from the laundry in resident rooms throughout the facility in an effort to maintain sufficient supplies on hand for care of their assigned residents had only exacerbated the problem. Continued interviews with LPNs #1, #2, and #3, on 12/3/15 at 2:20 PM, near the East Wing Nursing Station revealed all 3 nurses reported on a nearly daily basis for several months residents on their units had their showers delayed or postponed until the following shift due to shortages of clean towels and wash cloths. Continued interview revealed LPN #1 reported on multiple occasions staff nurses had complained to the former Director of Nursing (DON) and former Administrator about the shortages and were info… | 2019-01-01 |
| 5670 | 5670 | NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C | 445373 | 202 EAST MTCS ROAD | MURFREESBORO | TN | 37130 | 2015-09-02 | 356 | C | 0 | 1 | EE2W11 | Based on observation and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 1 of 3 days observed. The findings included: Observation on 8/31/15 at 9:55 AM, on the 200 hallway bulletin board, revealed the Posted Nurse Staffing was dated 8/30/15. Interview with the Director of Nursing (DON) on 8/31/15 at 10:00 AM, on the 200 hallway, confirmed the Posted Nurse Staffing was incorrect. | 2019-01-01 |
| 5702 | 5702 | SWEETWATER NURSING CENTER | 445456 | 978 HWY 11 SOUTH | SWEETWATER | TN | 37874 | 2016-01-06 | 372 | C | 0 | 1 | QMXV11 | Based on observation and interview, the facility failed to maintain a clean area, free of debris, for 2 of 2 dumpsters observed. The findings included: Observation with the Certified Dietary Manager (CDM), on 1/4/16 at 9:45 AM, of the dumpster area revealed 2 dumpsters with trash on the ground including 4 disposable gloves turned inside out and assorted paper and plastic trash. Further review revealed 1 dumpster had an opened door. Interview with the CDM on 1/4/16 at 9:45 AM, of the dumpster area confirmed the facility failed to maintain the cleanliness of the dumpster area. | 2019-01-01 |
| 5705 | 5705 | ASBURY PLACE AT KINGSPORT | 445481 | 100 NETHERLAND LANE | KINGSPORT | TN | 37660 | 2016-01-21 | 372 | C | 0 | 1 | J5QA11 | Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris for 4 of 4 dumpsters observed. The findings included: Review of facility policy, Infectious and Hazardous Waste, revised 10/14 revealed .all garbage, trash and other non-infectious waste will be stored and disposed in a manner that will not permit the transmission of disease .providing a breeding ground for insects and rodents .constitute a safety hazard . Observation with the Certified Dietary Manager (CDM) on 1/19/16 at 10:55 AM, at the dumpster area revealed 4 dumpsters with trash on the ground including 3 disposable gloves, 2 tied plastic bags with contents, plastic spoons, 1 used bandage, straws, and other paper trash. Interview with the CDM on 1/19/16 at 11:00 AM, at the dumpster area confirmed the facility failed to maintain a clean dumpster area. | 2019-01-01 |
| 5814 | 5814 | RENAISSANCE TERRACE | 445223 | 257 PATTON LANE | HARRIMAN | TN | 37748 | 2015-09-10 | 356 | C | 0 | 1 | DGX811 | Based on review of nurse staffing, observation, and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 2 of 4 days reviewed for nurse staffing posted. The findings included: Review of the Daily Nurse Staffing Form dated 7/3/15 revealed staffing included 1 Registered Nurse (RN) for 7:00 AM to 7:00 PM. Review of a facility investigation revealed the RN on 7/3/15 had left the facility at a undetermined time and returned after lunch. Interview with RN #3 on 9/10/15 at 1:30 PM, in the Assistant Director of Nursing Office, confirmed the Daily Nurse Staffing dated 7/3/15 was not correct because the facility was unsure what hours the RN was on duty 7/3/15. Observation on 9/8/15 at 9:10 AM, outside the Nurse Administration Room, revealed the Daily Nurse Staffing Form dated 9/8/15 indicated there were 4 RNs on duty. Observation on all three units in the facility on 9/8/15 revealed 1 RN was on duty. Interview with the Director of Nursing (DON) on 9/8/15 at 1:00 PM, in the conference room, confirmed the Daily Nurse Staffing Form was incorrect and the facility had 1 RN on duty on 9/8/15. | 2018-11-01 |
| 5877 | 5877 | MADISONVILLE HEALTH AND REHAB CENTER | 445457 | 465 ISBILL RD | MADISONVILLE | TN | 37354 | 2015-11-10 | 356 | C | 0 | 1 | ZD7T11 | Based on observation and interview, the facility failed to post the current Daily Nurse Staffing information. The finding included: Observation on 11/8/15, at 9:20 AM, in the entrance wing, revealed the Daily Nurse Staffing was dated 11/6/15. Interview with Licensed Practical Nurse #2 at 11/8/15 at 9:40 AM, in the entrance wing, confirmed the facility failed to post the current Daily Nurse Staffing information. | 2018-11-01 |
| 5939 | 5939 | LAURELBROOK SANITARIUM | 4.4e+201 | 114 CAMPUS DRIVE | DAYTON | TN | 37321 | 2015-08-12 | 161 | C | 0 | 1 | FXQD11 | Based on review of the facility Surety Bond, resident trust fund accounts, and interview, the facility failed to ensure the Surety Bond covered the amount in the Resident Trust for 44 of 49 residents. The findings included: Review of the facility's Continuation Certificate (surety bond) revealed .beginning 2/1/15 and ending 2/1/16 .amount of $35,000.00 .shall not exceed in the aggregate (overall) the amount written . Review of the Resident Trust Statement dated 8/11/15, revealed the current balance was $41,276.92. Interview with the Business Office Manager (BOM) on 8/11/15 at 2:30 PM, in the BOM's Office, revealed the facility had been over the $35,000 limit on several occasions over the past 6 months according to the monthly statements. Interview with the Administrator on 8/11/15 at 9:00 AM, in the Administrator's Office, confirmed the Resident Trust Fund balance was currently over the $35,000.00 surety bond limit. | 2018-11-01 |
| 6084 | 6084 | SIGNATURE HEALTHCARE OF CLARKSVILLE | 445448 | 198 OLD FARMER ROAD | CLARKSVILLE | TN | 37043 | 2015-07-09 | 356 | C | 0 | 1 | 9R4511 | Based on record review and interview, the facility failed to hold posted nurse staffing and census information for 18 months for the public to review upon request. The findings included: Review and interview of the Nurse Staffing/Census postings with the Staff Development Coordinator (SDC) on 7/6/15 revealed staffing postings for the last 18 months had not been kept. The SDC stated he/she had kept many of them, but they disappeared from his/her notebook. The SDC stated he/she started working in the facility in (MONTH) of this year and since that time staff filled out the posting forms daily, and then another staff person placed them in a book. The SDC stated the forms were missing, and he/she was not aware the postings had to be kept for 18 months. Interview on 7/8/15 at 11:36 P.M., the Administrator revealed he/she was not aware the nurse staffing and census forms had to be kept for 18 months. Interview on 7/8/15 at 4:08 P.M., the Director of Nurses (DON) stated he/she was aware the staffing and census forms were required to be kept for 18 months, and expected the assigned staff was keeping them according to the regulation. The DON acknowledged the facility staff did not keep the forms. | 2018-10-01 |
| 6140 | 6140 | LIFE CARE CENTER OF OOLTEWAH | 445511 | 5911 SNOW HILL ROAD | OOLTEWAH | TN | 37363 | 2015-09-17 | 356 | C | 0 | 1 | CDXL11 | Based on observation and interview, the facility failed to ensure an accurate daily Posted Nurse Staffing for 1 of 5 days. The findings included: Observation on 9/13/15 at 9:00 AM, outside the conference room revealed the Posted Nurse Staffing sitting on a table dated 9/12/15. Interview with the Registered Nurse (RN) #11 on 9/13/15 at 9:35 AM, outside the conference room confirmed the Posted Nurse Staffing was incorrect. | 2018-10-01 |
| 6187 | 6187 | RAINTREE MANOR | 445216 | 415 PACE STREET | MC MINNVILLE | TN | 37110 | 2015-06-03 | 167 | C | 0 | 1 | QLMP11 | Based on observation and interview, the facility failed to provide the most recent state survey results in a readily accessible location for all residents in the facility. The findings included: Observation on 6/1/15, at 10:15 AM, of the facility's posting titled, State Survey Results, located in the glass display of the facility's lobby revealed Copies of the most recent State Survey can be found in the Lobby, East and West Nurses Station, the Dir (Director) of Nursing's office and Administrator's office . Observation on 6/1/15, at 10:15 AM, revealed the survey results could not be located in the lobby. Observation on 6/1/15, at 10:22 AM, revealed the survey results could not be located at the West Nurses Station. Interview with Licensed Practical Nurse #2 (LPN) on 6/1/15 at 10:25 AM, at the West Nurses Station, confirmed, The survey results are not here on the west station right now. Interview with LPN #1 on 6/1/15 at 10:29 AM, at the West Nurses Station, confirmed, There are no survey results in the lobby. Interview with LPN #2 on 6/1/15 at 10:38 AM, in the conference room, confirmed the state survey results were not located in the areas specified on the State Survey Result document located in the lobby. | 2018-09-01 |
| 6238 | 6238 | PRINCETON TRANS CARE AT NORTH | 445356 | 400 NORTH STATE OF FRANKLIN ROAD | JOHNSON CITY | TN | 37601 | 2015-08-13 | 372 | C | 0 | 1 | 5QVH11 | Based on review of facility policy, observation, and interview, the facility failed to maintain a clean area, free of debris, for 1 of 1 dumpster reviewed. The findings included: Review of facility policy, Dumpster Cleaning Process, not dated revealed .rinse dumpster and area .pick up any remaining trash . Observation with the Dietary Director and the Patient Service Manager on 8/11/15 at 10:55 AM, at the 1 of 1 dumpster revealed on the outside of the dumpster the following: 1 empty plastic water bottle, 2 blue rubber gloves, a large plastic bag of trash, and other trash debris. Continued observation revealed a mixture of food debris and wet fluid under the dumpster flowing approximately 16 feet to the common driveway. Interview with the Dietary Director on 8/11/15 at 11:00 AM, at the dumpster confirmed .it's kind of nasty . Further interview confirmed the facility failed to maintain the cleanliness of the dumpster area. | 2018-09-01 |
| 6273 | 6273 | GALLAWAY HEALTH AND REHAB | 445440 | 435 OLD BROWNSVILLE RD | GALLAWAY | TN | 38036 | 2015-06-18 | 159 | C | 0 | 1 | XBDX11 | Based on policy review, review of residents' balances and interview, the facility failed to ensure residents receiving Medicaid funding balances did not exceeded the Supplemental Security Income (SSI) limit for 12 of 87 (Residents #19, 23, 33, 36, 47, 61, 66, 69, 76, 97, 98, and 100) residents with accounts in the facility during the first quarter of (YEAR) and for 14 of 87 (Residents #15, 23, 25, 36, 43, 57, 61, 63, 64, 66, 67, 69, 76, and 84) residents with accounts during the second quarter of (YEAR) as of (MONTH) 17, (YEAR), and the facility failed to provide a quarterly statement to a resident's (Resident #14) family member during the first quarter of (YEAR). The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, .5. At least every three months, the Facility shall furnish the Patient/Resident and other guardian, trustee, or conservator, if any, with a complete and verified statement of all funds and other property held by the Facility . 7. The Facility shall notify any Patient / Resident who receives Medicaid benefits when the amount in the Patient's / Resident's personal account reaches $200.00 less than the SSI resource limit for one person. This notice shall inform the Patient/Resident that if the amount in the account, in addition to the value of any of the Patient's/Resident's other non-exempt assets, reaches the SSI limit for one person, the Patient/Resident may become ineligible for Medicaid . 2. Review of the account balances as of 3/31/15 revealed the following balances: a. Resident #19 with a balance of $1,862.43 b. Resident #23 with a balance of $2, 728.66. c. Resident #33 with a balance of $1,900.80. d. Resident #36 with a balance of $1,963.52. e. Resident #47 with a balance of $2,134.12. f. Resident #61 with a balance of $2,408.73. g. Resident #66 with a balance of $2,407.47. h. Resident #69 with a balance of $3,481.04. i. Resident #76 with a balance of 18,153.05. j. Resident #97 with a balance of $2,453.24. k. Resident #98 wi… | 2018-09-01 |
| 6274 | 6274 | GALLAWAY HEALTH AND REHAB | 445440 | 435 OLD BROWNSVILLE RD | GALLAWAY | TN | 38036 | 2015-06-18 | 160 | C | 0 | 1 | XBDX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of account balances, medical record review and interview, the facility failed to refund 4 of 4 (Residents #95, 120, 121 and 122) deceased residents' balances to the residents' estates. The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, 6. Upon the death of a Patient/Resident who has personal funds deposited with the Facility, such Patient/Resident funds will be conveyed within 30 days to the individual administering the Patient's/Resident's estate . 2. Medical record review revealed Resident #95 expired on [DATE]. Review of the Resident #95's account as of (MONTH) 17, (YEAR) revealed a balance of $1,168.82 that had not been refunded to Resident #95's estate. 3. Medical record review revealed Resident #120 expired on [DATE]. Review of Resident #120's account as of (MONTH) 17, (YEAR) revealed a balance of $1, 527.75 that had not been refunded to Resident #120's estate. 4. Medical record review revealed Resident #121 expired on [DATE]. Review of Resident #121's account as of (MONTH) 17, (YEAR) revealed a balance of $192.13 that had not been refunded to Resident #121's estate. 5. Medical record review revealed Resident #122 expired on [DATE]. Review of Resident #122's account as of (MONTH) 17, (YEAR) revealed a balance of $882.36 that had not been refunded to Resident #122's estate. 6. Interview with the Business Office Manager (BOM) on [DATE] at 1:38 PM, in the business office the BOM gave the surveyor an account balance report and stated, There are residents on here that have expired. The surveyor asked the BOM if Resident #120's funds had been refunded. The BOM stated, Not refunded yet. Interview with the BOM on [DATE] at 10:00 AM, in the business office, the BOM was asked if refunds had been made to Resident #95, 121 and 122. The BOM stated, No, not closed or refunded yet. | 2018-09-01 |
| 6275 | 6275 | GALLAWAY HEALTH AND REHAB | 445440 | 435 OLD BROWNSVILLE RD | GALLAWAY | TN | 38036 | 2015-06-18 | 161 | C | 0 | 1 | XBDX11 | Based on policy review, review of the Patient Care Interest Bearing statements and interview, the facility failed to ensure the Surety bond was sufficient to cover the amount of money in the resident trust account for 2 of 3 (April and (MONTH) (YEAR)) months reviewed. The findings included: 1. The facility's PROTECTION OF PATIENT/RESIDENT FUNDS AND BENEFICIARY DESIGNATION policy documented, .8. The Facility will purchase a surety bond or, as allowed by law, provide self-insurance to assure the security of all personal funds of Patients/Residents deposited with the Facility . 2. The Patient Care Interest Bearing bank statements documented the following: a. (MONTH) 1, (YEAR) through (-) (MONTH) 30, (YEAR): Daily ledger balance summary was $102,866.14. b. (MONTH) 1, (YEAR) - (MONTH) 31, (YEAR): Daily ledger balance summary was $131,545.79. Interview with the Business Office Manager (BOM) on 6/17/15 at 1:45 PM, in the business office, the BOM was asked if she was aware the average daily balance exceeded the facility's surety bond of $100,000.00. The BOM stated, Yes I noticed it when I printed it off and it's not covered. | 2018-09-01 |
| 6361 | 6361 | BROOKHAVEN MANOR | 445174 | 2035 STONEBROOK PLACE | KINGSPORT | TN | 37660 | 2016-12-07 | 356 | C | 0 | 1 | E8N511 | Based on observation and interview, the facility failed to accurately post the daily nurse staffing data for 2 of 9 days observed. The findings included: Observation on 11/19/16 at 10:10 AM, in the lobby, revealed .Today's Staffing .Day shift .Night shift .Census 100 . Further review revealed the posted staffing was dated 11/18/16. Interview with Registered Nurse (RN) #6 on 11/19/16 at 10:35 AM, at the 300-400 nurses station, confirmed the posted staffing was dated 11/18/16 (1 day prior) and the facility .had not posted the nurse staffing sheet yet . Observation on 11/28/16 at 9:55 AM, in the lobby, revealed .Today's Staffing .Day shift .Night shift .Census 104 . Further review revealed the posted staffing was dated 11/23/16. Interview with RN #6 on 11/28/16 at 10:16 AM, in the lobby, confirmed the facility posted staffing was dated 11/23/16 (5 days prior) and the facility failed to post the current daily staffing. | 2018-08-01 |
| 6406 | 6406 | TRENTON HEALTH AND REHABILITATION CENTER, LLC | 445308 | 2036 HIGHWAY 45 BYPASS | TRENTON | TN | 38382 | 2015-05-06 | 356 | C | 0 | 1 | 8S8X11 | Based on observation and interview, the facility failed to ensure staffing information was posted on 3 of 3 (5/4/15, 5/5/15 and 5/6/15) days of the survey. The findings included: Observations revealed the staffing was not posted as followed: a. On 5/4/15 at 9:30 AM, 11:00 AM and 3:00 PM. b. On 5/5/15 at 7:30 AM, 10:30 AM, 2:00 PM and 5:00 PM. c. On 5/6/15 at 7:15 AM and 9:00 AM. Interview with the Director of Nursing (DON) on 5/6/15 at 9:50 AM, at the nurses station, the DON was asked where the staffing was posted. The DON stated, It's usually right there (pointing to an area on the wall across from the nurses station). The DON verified the staffing was not posted. Interview with the Assistant Director of Nursing (ADON) on 5/6/15 at 10:15 AM, in the conference room, the ADON was asked about posting of the staffing. The ADON stated, Typically it's posted every morning, just haven't done it this week. | 2018-08-01 |
| 6478 | 6478 | NHC HEALTHCARE, LAWRENCEBURG | 445180 | 374 BRINK ST PO BOX 906 | LAWRENCEBURG | TN | 38464 | 2015-02-04 | 371 | C | 0 | 1 | ML4B11 | Based on policy review, review of the kitchen cleaning schedule and observation, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidenced by the presence of dark brown, gritty dust buildup under the edge of freezer #1 and failed to distribute food under sanitary conditions as evidenced by 2 of 2 staff members (Register Health Information Technician (RHIT) #1 and Certified Nursing Assistant (CNA) #1) entered the kitchen without a hair net. The facility has 92 of the 96 residents who receive a meal tray from the kitchen. The findings included: 1. Review of the facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .Sweep and spot mop after each meal and as needed; thorough mopping daily; scrubbing/brushing weekly . Review of the facility's kitchen cleaning schedule documented, .sweep, mop, clean and straighten . Observations in the kitchen on 2/2/15 at 10:28 AM and 2/3/15 at 7:50 AM, revealed the presence of dark brown, gritty dust buildup under the edge of freezer #1. 2. Observations in the kitchen on 2/3/15 at 10:14 AM, revealed RHIT and CNA #1 in kitchen area without a secured hair. Observations in the hall outside the kitchen on 2/4/15 at 9:31 AM, revealed signs PATIENTS RING BELL FOR SERVICE and DIETARY SERVICES. Observation revealed hair restraint covers available in the hall before entering the door to the kitchen area. | 2018-07-01 |
| 6606 | 6606 | SIGNATURE HEALTHCARE OF PUTNAM COUNTY | 445136 | 278 DRY VALLEY RD | COOKEVILLE | TN | 38506 | 2015-02-04 | 372 | C | 0 | 1 | WR7L11 | Based on observation and interview, the facility failed to dispose of garbage properly to maintain sanitary conditions. The findings included: Observation of the garbage and refuse dumpster on February 4, 2015, from 8:05 a.m. until 8:10 a.m., revealed two of three garbage dumpsters had two lids open with black and white trash bags overstuffed and hanging out of the dumpsters. Interview with the Registered Dietician on February 4, 2015, at 8:10 a.m., in the dumpster area outside the laundry room entrance confirmed the lids were open, plastic bags of refuse were overstuffed, hanging out of the dumpsters, the lids were not closed, and refuse was not contained. | 2018-05-01 |
| 6697 | 6697 | CHURCH HILL CARE & REHAB CTR | 445237 | 701 WEST MAIN BLVD | CHURCH HILL | TN | 37642 | 2015-02-03 | 356 | C | 0 | 1 | 50D411 | Based on observation and interview, the facility failed to post current facility staffing. The findings included: Observation on February 1, 2015, at 9:43 a.m., in the hall adjacent to the AB Hall nurse's station revealed a wall-mounted staff posting sheet dated January 30, 2015. Interview with Registered Nurse #8 on February 1, 2015, at 9:45 a.m., in the hall in front of the AB Hall nurse's station, confirmed the staff posting was not the current date. Observation on February 1, 2015, at 9:48 a.m., in the hall adjacent to the CD Hall nurse's station revealed a wall-mounted staff posting sheet dated January 30, 2015. Interview with Licensed Practical Nurse #2 on February 1, 2015, at 9:50 a.m., in the hall in front of the CD Hall nurse's station, confirmed the staff posting was not the current date. | 2018-05-01 |
| 6714 | 6714 | SUMMIT VIEW OF FARRAGUT, LLC | 445258 | 12823 KINGSTON PIKE | KNOXVILLE | TN | 37923 | 2015-02-27 | 356 | C | 0 | 1 | V17V11 | Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on February 23, 2015, at 7:35 a.m., in the facility front hall, revealed the nurse staffing sheet was dated February 20, 2015. Interview with Licensed Practical Nurse #2 on February 23, 2015, at 8:15 a.m., in the facility front hall, confirmed the nurse staffing sheet posted was not for the current date. | 2018-05-01 |
| 6719 | 6719 | CUMBERLAND HEALTH CARE AND REHABILITATION INC | 445262 | 4343 ASHLAND CITY HWY | NASHVILLE | TN | 37218 | 2014-10-09 | 156 | C | 0 | 1 | ZBLF11 | Based on record review and interview, it was determined the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #26, #66 and 115) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 05-26-2014 . Telephone contact with the representative was made on 5/22/14. There is no documentation the telephone contact was confirmed by written notice on that same date. 2. Review of the Notice of Medicare Non-Coverage for Resident #66 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 08-14-14 . There is documentation with Resident #66's signature dated 8/18/14, four days after notification of Medicare Non-Coverage days. 3. Review of the Notice of Medicare Non-Coverage for Resident #115 documented, .The Effective Date Coverage of Your Current Skilled Nursing Services Will End: 06-06-2014 . Telephone contact with the representative was made on 5/22/14. There was no documentation the telephone contact was confirmed by written notice on that same date. 4. During an interview in the hallway on 10/8/14 at 6:30 PM, the Social Worker was asked to provide documentation where the Responsible Party had been notified in writing of the resident's Notice of Medicare Non-Coverage letter. The Social Worker stated, No, I do not have proof that I gave them a copy of the letter. The Social Worker was asked to verify the dates on Resident #66 Notice of Medicare Non-Coverage letter. The Social Worker stated, Oh, I can't believe I did that . I have the dates backward. | 2018-05-01 |
| 6725 | 6725 | LIFE CARE CENTER OF JEFFERSON CITY | 445275 | 336 WEST OLD ANDREW JOHNSON HWY | JEFFERSON CITY | TN | 37760 | 2015-03-10 | 356 | C | 0 | 1 | W72C11 | Based on observation and interview, the facility failed to post accurate nurse staffing information as required. The findings included: Observation on March 8, 2015, at 8:55 a.m., at the entrance hallway revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for Saturday, March 7, 2015, and had not been updated to reflect current nursing staff in the facility on March 8, 2015. Interview with the Licensed Practical Nurse #3, at the time of the observation on March 8, 2015, confirmed the staffing information did not reflect the current nursing staff present and confirmed the facility failed to post accurate staffing. | 2018-05-01 |
| 6726 | 6726 | REELFOOT MANOR HEALTH AND REHAB | 445285 | 1034 REELFOOT DRIVE | TIPTONVILLE | TN | 38079 | 2015-01-15 | 244 | C | 0 | 1 | T0F711 | Based on policy review, review of the resident council minute reports and interview, it was determined the facility failed to promptly resolve grievances related to residents not getting coffee before the meal trays as documented in the minutes for 3 of 3 (October, November and December 2014) months of minutes reviewed. The findings included: 1. Review of the facility's residents' rights policy documented, .(f) Grievances. A resident has the right to-- (1) Voice grievances . (2) Prompt efforts by the facility to resolve grievances the resident may have . Review of the facility's filing grievances / complaints policy documented, .5. Upon receipt of a grievance and/or complaint, the Social Worker will investigate the allegations and submit a written report of such findings the Administrator within (5) working days of receiving the grievance and/or complaint . 6. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken . 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility . 2. Review of the October 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 3. Review of the November 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 4. Review of the December 2014 resident council minutes documented the residents' concern of coffee not being served before the meal trays are delivered. 5. During an interview in the Social Service office on 1/13/15 at 8:46 AM, the Human Resource Director was asked about the facility's response to the council's problem with getting the c… | 2018-05-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );